annual plan 2009 / 10oxleas.nhs.uk/site-media/cms-downloads/oxleas... · page 3 of 87 introduction...

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Annual Plan 2009 / 10

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Contents Page

1. Introduction to the trust ………………… 3 – 7

2. Past Year Performance ………………… 8 – 30

3. Our Priorities and Plans for the Future

………………… 31 – 71

4. Risk Analysis

………………… 72 – 78

5. Declarations and Self-Certification ………………… 79 – 80

6. Membership ………………… 81 - 87

7. Appendices

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Introduction to the trust 1.1 Our services Oxleas NHS Foundation Trust offers a wide range of health and social care services in South East London caring for people with mental health problems or learning disabilities. We have been the main provider of specialist mental health and learning disability care in Bexley, Bromley and Greenwich for more than 10 years and have developed a comprehensive portfolio of services in community and hospital settings.

The development of Oxleas NHS Foundation Trust

1994 The trust is formed as Bexley Community trust, providing mental health, forensic, learning disability and community services.

1995 Oxleas is formed, as the trust assumes responsibility for mental health and learning disability services in Greenwich and specialist forensic services for Lewisham and North Southwark.

1997 Oxleas incorporates Bromley’s child and adolescent, adult and older adult mental health services.

2001 Oxleas incorporates Greenwich and Bexley child and adolescent mental health services.

2006 2007 2009

Oxleas achieves foundation trust status.

Oxleas incorporates Bromley adult learning disability services.

Oxleas becomes the lead provider of the Increasing Access to Psychological Therapies services in Greenwich

The trust has Section 75 partnership agreements in place with the London Boroughs of Bexley, Bromley and Greenwich and is the lead provider of mental health and social care for working age adults across the three boroughs. Oxleas also provides services to HMP Belmarsh and forensic mental health care across South East London. We offer services for people of all ages and work closely with a variety of partners to ensure that our services are well integrated and comprehensive. We have a workforce of around 2000 people from a wide range of health and social care professions and other groups. We became a foundation trust in May 2006, following several years as a high-performing NHS trust. We were one of the first mental health trusts in the country to benefit from the greater freedom offered by foundation trust status under the Health and Social Care Act 2003. The trust currently delivers services from 76 buildings across 49 sites within its three constituent boroughs. At the beginning of this year, Oxleas had an active caseload of more than 17,000 service users. The table shows how this caseload is distributed between our different care groups.

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Trust Caseload Distribution

Service 31st March 09 % of Total

Working Age Adults 8,444 48%

Older Adults 4,283 25%

Forensic Services 516 3%

CAMHS 2,631 15%

Adult Learning Disability 1,522 9%

Total 17,396

N.B. Service users on the caseload of more than one team within a given service have been counted only once. 1.2 Our purpose and values Our organisational purpose and values are the foundations for everything we do. Our purpose is:

To improve lives by providing the best quality health and social care for our service users and their carers.

This statement confirms that our principal focus is on the quality of the services we provide. We believe that the communities we serve expect and deserve to receive the best care available anywhere within the NHS and it is our responsibility to provide this. We also recognise that many people using our services have long-term conditions that cannot completely be alleviated. However, everyone using Oxleas services can expect to receive help and support which aims to improve the quality of their lives. We have identified six values to help us achieve our purpose and communicate to service users, carers and stakeholders how they can expect to be treated by any employee of Oxleas. Value What this means for service users, carers and stakeholders

User focus • We view things through the eyes of our service users and carers.

• We listen to the views of service users and carers and we respond.

• We provide our diverse community of service users and carers with information and support to make their own choices.

Excellence • We are never content with performance or a level of service that is second best.

• We strive to be at the forefront of innovation, providing the best possible care for every pound we receive.

• We treat everyone who comes into contact with our services with courtesy, dignity and respect.

Learning • We are open to feedback on our services and respond honestly and constructively.

• We challenge ourselves to review and improve the way we do things.

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Value What this means for service users, carers and stakeholders

• We address gaps in our knowledge and competencies at all levels of the organisation.

Responsive • We eliminate unnecessary delays for treatment, care and advice.

• We make it as easy as possible for service users, carers and stakeholders to make contact with our services and receive appropriate support.

• We make decisions and take action at the first time of asking.

Partnership • We work with other stakeholders and value their contribution to the provision of integrated health and social care.

• We work with others to ensure our service users and carers receive support in accessing occupation, leisure, welfare, housing and physical health care.

• We promote team working and encourage both individual and collective responsibility.

Safety • We do all that we can to ensure that no harm comes to our service users, our staff or the public.

• We focus upon best practice in therapeutic risk taking.

This set of values is drawn from an extensive consultation process with staff, service users, carers, members and governors. The values are a key part of the trust’s induction programme and we are working to embed them within our recruitment processes; they also form the structure of the trust’s annual staff awards. 1.3 Our Quality Drivers - the four ‘must dos’ In 2007, to identify those quality-related issues most pertinent to service users and carers, we utilised the responses to our 2007 National Patient Survey. Based on the survey results and led by the Board, we developed four ‘must dos’ that have remained at the forefront of our annual plan commitments.

Organisational ‘Must Dos’

1. Support families and carers.

2. Provide information for our service users and their carers.

3. Enhance care planning.

4. Improve the way we relate to both service users and their carers.

The ‘must dos’ support the three components of delivering quality: patient safety, patient experience and clinical effectiveness and ensure that improving quality at the point of service delivery is at the forefront of the Board’s work and that of all our staff. These trust wide priorities form the basis for the quality report in our 2008/9 Annual Report.

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1.4 Meeting our strategic objectives The trust has five strategic objectives that underpin our purpose and values and provide the starting point for identifying the key work streams each year. Purpose Values Strategic Objectives

To improve lives by providing the best quality health and social care to our service users and their carers.

User focus Excellence Learning Responsiveness Partnership Safety

To promote social inclusion for all our users.

Consistently to deliver excellent quality, safe and responsive services.

To engage users, carers, public and partners in the governance and planning of our services.

To develop a fully engaged, motivated and skilled workforce.

To ensure value for money in all our services.

Each year we consider how to meet our strategic objectives in the context of the environment in which we will be operating, considering factors such as:

• Regulatory frameworks;

• Anticipated political, economic, social and technological changes;

• The market and competition;

• Demand;

• Our organisational capacity.

In 2008/9, we identified 10 priority work streams in addition to our four ‘must dos’ that enabled us to continue to meet our strategic objectives. Strategic Objectives Priority work streams

To promote social inclusion for all our users.

1 Promote social inclusion

Consistently to deliver excellent quality, safe and responsive services.

• Must do – support families and carers

• Must do – provide information for our service users and their carers

• Must do – enhance care planning

• Must do – improve the way we relate both to service users and carers

2 Improve the delivery of acute and crisis care

3 Implement the new mental health legislation

4 Implement evidence-based care pathways

5 Increase access to psychological therapies

To engage users, carers, public and partners in the governance and planning of our services.

6 Develop the role of our governors and members

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Strategic Objectives Priority work streams

To develop a fully engaged, motivated and skilled workforce.

7 Ensure excellence in leadership and management

8 Maintain our profile by developing new initiatives, increasing marketing activity and participating in nationally recognised schemes

To ensure value for money in all our services.

9 Ensure our finances are robust

10 Improve data quality and the use of information across the trust

A set of targets was identified for each work stream and the ‘traffic light’ tables in 2.4 – 2.13 summarise our progress against these in 2008/09.

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2. Past Year Performance 2.1 Chief Executive’s summary

I am very pleased to report that during 2008/09 we made major progress across all parts of the trust towards achieving our purpose of providing the best quality health and social care for local patients and carers.

We were delighted to receive an excellent rating for the quality of our services and an excellent rating for the use of resources from the Healthcare Commission in the NHS Performance Ratings. In addition, we fully met each of Monitor’s indicators for mental health Foundation Trusts and finished the year with a financial risk rating of 5 from Monitor; the lowest risk rating possible.

Our high levels of performance have been achieved by an unremitting focus at all levels of the organisation on delivering our 4 ‘Must Dos’ and our priority work streams. Our must dos were developed in conjunction with our staff, members and governors as our key drivers for quality improvement and were primarily drawn from patient feedback in the previous years National Patient’s Survey. Our must dos cover a range of actions which are aimed at improving information to users and carers; increasing involvement for users in their care and treatment; enhancing relationships with our staff; and increasing support to families and carers. As a result, we have made significant progress in each area and this translated into improved ratings in 20 out of 27 categories in our 2008/09 National Patients Survey. The Board of Directors considers feedback from patients and carers as the most critical indicator of the quality of our services. The results of our Patient Survey were, therefore, particularly gratifying. Nevertheless, we recognise that our service users still gave less positive feedback than users in comparable trusts for around half of the areas in the survey. During 2009/10 we are therefore continuing our focus on delivering our 4 must dos and have consulted with our members, governors and commissioners on the other standards we need to address. These are included in our Quality and Safety Improvement Plan.

During 2008/9 we had a particular focus on the quality of treatment received by our most vulnerable service users in our acute inpatient services. This followed our rating of ‘good’ in the Healthcare Commission’s National Review of Acute Inpatient Services. Our actions focussed upon improving patients’ safety and experience as well as the quality and cleanliness of the environment. We were therefore pleased to receive Patient Environment Action Team (PEAT) scores of ‘excellent’ in 35 of 39 inpatient areas inspected for the quality of the environment, food and privacy and dignity. To ensure continuing improvements in in-patient services we have introduced electronic Patient Experience Trackers in each acute unit. This enables patients to provide feedback each day on the quality of the environment and how well we are meeting our pledges in our 4 must dos.

We have always maintained that the quality of services received by users and carers is directly linked to the quality of our staff. We were particularly proud, therefore, to receive our best ever results in the 2008 NHS Staff Survey. Our staff rated us as being amongst the best 20% of mental health trusts for 21 out of 36 key areas. Furthermore, we were the best rated mental health trust in the country in 8 areas, including whether our staff felt they could make a difference to patients; whether they received the training and development they need; and whether they felt valued. We

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are confident these outstanding results will enable us to continue to recruit and retain the best staff and this will benefit both patients and carers.

There was one area where staff rated us less highly than in 2007. This was the uptake of flexible working options and we will redouble our efforts in this area to increase the number of staff taking advantage of the arrangements that are available to them.

Our financial performance remains strong with our retained surplus before exceptional items higher than planned. Our cash balances also improved and were ahead of plan. This performance was achieved through successfully marketing our secure and intensive care beds to generate extra income alongside tight control of traditional areas of cost pressure such as drugs and temporary staffing. Our major risk continues to be the high demand for inpatient services leading to cost pressures arising from out of area placements. We are focussing upon developing the most effective bed management processes as well as working with commissioners to increase capacity in our home treatment services to provide effective alternatives to admission.

The biggest development during the year was the decision in January of Bexley Care Trust to transfer the Community Health Services to Oxleas. We believe we have the right organisational culture, experience and expertise to support the delivery of high quality community health services. We also think local people will benefit from a coordinated and holistic approach to the assessment and treatment of both physical and mental health conditions. We are developing a robust business case to demonstrate how we intend to deliver high quality, safe and value for money services. We expect to welcome the new services into Oxleas towards the end of 2009/10.

This Annual Plan sets out our ambitious plans and priorities for the current year and details how we will manage the associated clinical, governance and financial risks. We look forward to working with our staff, governors, members and local stakeholders to deliver on these commitments and contributing to the improved health and well being of the people we serve in south east London.

Stephen Firn Chief Executive

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2.2 Improving quality In 2008/9, 8 of our 14 priority work streams (including the four ‘must dos’) addressed our ability to ‘consistently deliver excellent quality, safe and responsive services’. All these work streams relate to the three elements of quality required in our quality report, that is, patient safety, clinical effectiveness and patient experience. The priority work streams had measurable objectives for 2008/9 that were monitored by the Board and the Council of Governors (see below); our success in meeting these objectives were reflected in the Healthcare Commission and Monitor ratings. 2.2.1 Healthcare Commission ratings In 2008, the Healthcare Commission judged Oxleas to have made ‘excellent’ use of resources (this score was derived from the trust’s Monitor rating – see 2.5) and to have delivered ‘excellent’ quality services. The quality of services score comprised three component assessments:

Component Assessment Rating

Core standards Fully met

Existing national targets Fully met

New national targets Excellent The table below detail our performance in each of these areas:

ANNUAL HEALTH CHECK 2008

Core Standards There are 24 standards intended to ensure that services are safe, equitable and of acceptable quality. The standards are grouped into six areas

Level of performance

Percentage of trusts achieving indicator

• Safety

• Clinical and cost effectiveness

• Patient focus

• Accessible and responsive care

• Environment and amenities

• Public Health

Fully met 80.3%

Existing National Targets Level of performance


Improve life outcomes of adults and children with mental health problems by ensuring that all patients who need them have access to crisis resolution services and a comprehensive child and adolescent mental health services.

Fully met 100%

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New National Targets Level of performance


Overall performance Excellent 78.6%

Achieve year-on-year reductions in MRSA levels, expanding to cover other healthcare associated infections as data from mandatory surveillance becomes available.

Achieved 95.7%

Halt the rise in obesity among children by 2010, as part of a broader strategy to tackle obesity in the population as a whole.

Achieved 100%

Improve health outcomes for people with long term conditions by offering a personalised care plan for vulnerable people most at risk and reduce emergency bed days by 2008 through improved care in primary care and community settings for people with long-term conditions.

Achieved 88.2%

Improve the quality of life and independence of vulnerable older people by increasing the proportion of older people being supported to live in their own home by 2008,

Achieved 79.2%

Reduce health inequalities by 2010 (ethnic coding). Achieved 98.5%

Secure sustained national improvements in NHS patient experience by 2008. Achieved 86.7%

Substantially reduce mortality rates from 2010 from suicide and undetermined injury. Achieved 99%

2.2.2 Monitor’s ratings The trust was also compliant with Monitor’s four key quality indicators for mental health foundation trusts:

(1) Ensure that at least 95% of all enhanced patient discharges are followed up within seven days.

(2) Maintain the level of crisis resolution home treatment (CRHT) teams agreed in the 2003/06 planning round.

(3) Ensure that the level of delayed transfers of care does not exceed 7.5%

(4) Ensure that at least 90% of admissions have access to crisis resolution services.

The delayed discharge target proved particularly challenging for our older adult services. However, focused work with local authority partners to reduce delays in the funding decision process and the care home placement processes was successful in reducing the number and length of delays. This joint work will continue during 2009/10. We are also working with partners to consider whether the development of new continuing care services for older adults with dementia within

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the trust may reduce the time that service users are inappropriately delayed within acute care beds. 2.3 Four ‘must dos’ The 2007 National Patient Survey made it clear that there were four key areas where service users wanted us to do better:

• Better information and support for their families and carers

• More information about their treatment

• More involvement in their care

• Better relationships with staff We launched a trust wide action plan to ensure immediate and sustainable improvements. Over the past eighteen months, we have seen strong improvements across the trust and have been praised by our Council of Governors for our ‘positive and appropriate’ response to the NPS results and our commitment to improving the experiences of service users and carers. The table below summarises some of the work we undertook to take forward our four must dos: 1. Support families and carers

The trust Carers’ Strategy and Carers’ Handbook were launched and carer focus groups were held in every borough.

Family inclusive practice training has been piloted and will be rolled out across the service directorates.

Team-by-team training workshops are taking place to show staff how to register carers on RiO (our electronic patient information system) and undertake carers’ assessments.

A wide range of multimedia information for staff to provide to carers was added to the user / carer section of the trust’s intranet.

All Oxleas inpatient units and many community teams now run carer support groups.

The Healthcare Commission reaudit of the NICE guidelines for schizophrenia, which included our ability to deliver family therapy, showed improvement from the first audit in 2006.

2. Provide information for our service users and their carers

A major redesign of the intranet was undertaken to provide accessible service user and carer information. The project was in the top five short listed for a national HSJ award.

The pharmacy action plan has been implemented, this included the production and distribution of standard information leaflets and the launch of a medication phone line.

A national ‘Information Prescriptions’ pilot was completed in Bromley. The pilot is regarded as the leading national mental health Information Prescription programme for long-term complex conditions and is being used as the model to be rolled out in the National Information Prescriptions Implementation Plan. Materials developed in the pilot are now available via the intranet to benefit the whole trust.

Information for carers has been developed through a collaboration with Tate Gallery. The Carer podcast project has been given a national award, published in a national journal and newspaper, and has now been awarded national funding.

A website for children and adolescents with mental health problems www.CamhsCares.nhs.uk has been launched and work is taking place with local schools

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to provide more information for young people on keeping mentally well.

Accessible information leaflets are being produced for adult learning disability service users.

All core trust services have an information leaflet providing details on the care and services they provide.

3. Enhance assessment and care planning

Oxleas has led the development of a national self assessment tool to support trusts to implement the requirements of the new Care Programme Approach (CPA) guidance.

The trust’s Service Line Reporting Programme is underway in adult, older adult and forensic & challenging behaviour services. The programme will develop a standard set of needs-led and best practice care packages and care plans.

Work is underway to ensure that every team has an operational policy that is fit for purpose and includes care planning.

RiO (our electronic patient record system) is being used to support more effective care planning – e.g. ‘live’ completion of care plans, ward rounds and CPA reviews.

All service users have been provided with a crisis contact card.

The intranet now includes an innovative “Evidence for Practice” clinical decision support section. Information and best practice tools are available to support diagnosis, assessment, implementation of NICE guidance and evaluation of clinical practice.

Oxleas has implemented physical healthcare and healthy lifestyle programmes on all inpatient units and in several community units. This work has been cited as a model of good practice in several national publications including Star Wards and presentations at the London physical health launch and the national acute care summit.

The coding project has allowed a greater understanding of the holistic needs of our service users supporting plans for developing services to more effectively meet service user needs.

Practical toolkits were developed to enable service users to access a wider range of support services in the community.

4. Improve the way we relate both to service users and carers

Hand-held patient experience trackers (PETs) have been piloted within our inpatient units to provide frontline teams with rapid feedback. The feedback given through this system has resulted in cleaner wards.

Our Patient Environment Action Team (PEAT) scores in 2008/09 were ‘excellent’ in 35 of the 39 areas inspected on quality of environment, food and privacy and dignity. The three remaining areas were scored ‘good’.

Senior staff from all disciplines are leading by example in wards rounds, CPA reviews and key service user and carer interactions.

A trust-wide campaign has been implemented to embed the organisation's values. The campaign included revising our recruitment and induction processes to ensure that the trust's commitment to providing excellent customer care is highlighted and promoting the values across all trust sites. A survey of staff showed high recognition of the trust's values and a strong belief that they support them in their work.

Service user consultants and expert by experience trainers have increased in numbers.

Welcome packs have been introduced for all new patients admitted to Oxleas’ inpatient wards.

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The improvement in our scores in each of the four ‘must do’ areas in the 2008 National Patient Survey demonstrates the effectiveness of our efforts (appendix i). In 24 instances, our scores bettered or matched our 2007 scores and in 13 instances, our scores were higher than the comparator average. Significant improvements were made in all areas of the survey and we performed particularly well in providing information and improving care planning. In order to gain more regular user feedback, we introduced the Dr Foster Patient Experience Trackers (PETs) as a pilot within our Greenwich Directorate services. Questions asked were based on the four ‘must dos’ and safety and cleanliness. In 2009, the PETs will be in use in all acute wards; they will support our ability to report on patient reported outcome measures (PROMS) and carer reported outcome measures (CROMS) as required within our quality report in 2009/10. The sections that follow detail our progress in our ten priority work streams. 2.4 Promoting social inclusion This work stream made achievements against all the agreed targets for 2008/9. The trust social inclusion steering group has engaged with governors, members and partner organisations and a new work plan was put in place in early 2009. The Executive established a post to lead for social inclusion trust wide and agreed to continue funding a social inclusion project worker post and establish service directorate leads for social inclusion. Social Inclusion Achievements

Hold event to promote the employment of people with MH problems / LD

Employer engagement event held with the South London Chamber of Commerce at the O2.

External training to local independent HR provider on Managing Mental Health in the Workplace – training package now available for use.

Stall at CSP Launch Event Dec 2008 promoting mental health and employment.

Time to Change campaign materials sent to 50 local employers in February 2009.

Provide service users with a discharge pack that identifies suitable services and community agencies for them to access in the community.

Discharge pack now complete and uploaded onto the intranet – copies introduced to care co-ordinators at local meetings to facilitate use (additional local information to be added in 2009/10)

Launch a local media campaign to promote awareness of mental ill-health or establish a ‘media alerters’ scheme.

‘Write Way’ scheme established and launched in May with more than 55 members across the trust.

Over 6 media presentations highlighting stigma and mental health delivered to Write Way membership.

Implement the principles from ‘The Mindful Employer’

Trust achieved ‘Mindful Employer’ status.

Training for 18 HR staff on managing mental health in the workplace has been completed.

Planning begun for provision of a revised occupational health service in support of the mindful employment culture.

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Social Inclusion Achievements

Revised Staff Stress Policy agreed and new stress assessment developed to support and monitor implementation.

Results from National Staff Survey 2008 indicate highly positive progress on NHS Staff Pledge 3 – Health & wellbeing of staff

Support the development of a mental health awareness training library.

This information is now available and is to be developed into a formal training package in collaboration with our local PCTs

Formal training has taken place with local employers and the trust action on the Time to Change campaign has included direct mail outs to over 50 local employers with information and resources.

Develop service-specific good-practice guidance on the trust intranet re: assessment of loneliness, social networks and social participation.

Develop good quality, accessible information and advice on the trust intranet for staff, service users and carers to encourage social activities.

A discharge-from-services guidance pack has now been uploaded on to the intranet and an e-forum for employment issues [practice based] has been established [31 members trust wide]

A trust wide Peer Support workshop was held in March 2009 [25 attendees]

Social inclusion is now part of the mandatory induction programme for all new staff – this has included over 230 January 2008 – March 2009.

Information is available on the intranet under the areas of:

• Community participation

• Supporting participation

• Barriers to participation

Establish competency-based recruitment to clinical teams.

Competency-based recruitment programmes are in place for nursing and band 5&6 OT staff.

Plans are in place to roll out to other areas in 09/10.

Increase number of transitional employment placements by 3.

Plans are in place to implement a ‘Volunteer to Work’ scheme; this will make a minimum of 12 placements available for immediate implementation in early 2009/10

The TEP scheme managed by Horizon House in Bromley has also increased local provision and plans a celebration and information event in May 2009.

Planning work in conjunction with finance director and partners has been undertaken to support the development of social enterprise locally to create greater employment and meaningful activity opportunities for users.

Ensure 100% completeness of employment status recording on RiO.

The trust position is 57% for working age adults. Bexley directorate has achieved 72% completeness. This will be a key rollover target for all service directorates in 2009 / 10.

Extend the volunteer project in Greenwich to one other borough

The volunteering policy has been approved by the SI steering group. This will be ratified by the relevant governance groups and agreed with staff side – formal implementation will begin at the start of 09/10. This policy

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Social Inclusion Achievements will support the volunteer to work placements and other types of volunteering within the trust.

Ensure that care-coordinators access the training module in capabilities for inclusive practice.

Module developed with the University of Greenwich but insufficient numbers applied to run the course. Alternative teaching mechanisms based at team level are to be piloted in 2009.

A SI interactive presentation for Bexley staff, service users and other was included in the Recovery seminars in 2008.

Presentations were also given to Greenwich medical teams and all service directorates.

Increase the number of service users in >16 hours paid employment by 5%.

A robust baseline position has not yet been established (insufficient data completeness).

This is a key roll over target for 2009 / 10.

2.5 Improve the delivery of acute and crisis care During 2008/9, the Healthcare Commission undertook a national review of acute inpatient services. Trusts were rated in four areas:

(1) Patients are admitted to hospital when it is appropriate for them and they stay in hospital no longer than necessary.

(2) Services focus on the needs of the individual and provide care that is personalised and promotes recovery and inclusion.

(3) Service users and carers are involved in planning their own care, how the ward is run and helping to improve the service.

(4) The ward has approaches in place to make sure that patients, staff and visitors are safe.

The national ratings distribution is set out in the table below:

Rating % of MH trusts

Excellent 10.4%

Good 29.9%

Fair 43.4%

Weak 16.4% Oxleas was rated as ‘good’; only one trust in London was rated as ‘excellent’. Progress against our annual plan targets are as follows: Acute and Crisis Care Achievements

Establish a 24/7 CRHT response that can be accessed by all service users.

In place in each borough.

Minimise delayed transfers of Met Monitor’s target of less than 7.5% delayed discharges

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Acute and Crisis Care Achievements care from WAA beds to maximum of 7.5%.

across trust beds.

Achieve 10% increase in the number of people treated at home by the CRHT from 31 March baseline.

Significantly over achieved with an increase of 100% on the 2007/08 baseline.

Ensure that users and carers know how to access help and advice in a crisis, 24/7.

In last year’s National Patient Survey, only 48% of those surveyed said that they knew how to access services out of hours (comparator average of 50%). In this year’s survey, this percentage had increased to 58% (comparator average of 51%).

Eliminate sleepovers in other units and reduce the level of sleepovers by 50% from 07/08 average.

Sleepovers in other units have been successfully eliminated. Sleepover episodes within units were 46% lower in March 2009 than April 2008.

Undertake options appraisal to establish a women-only ward in inpatient rehabilitation and acute services.

This work is being progressed via cross-trust forums involving clinical and senior management leads. We are reviewing the feasibility of women-only acute wards.

Achieve an average occupancy of 105% including leave on each acute inpatient ward.

While the target of 105% has not been realised, a significant reduction in average occupancy has been achieved. The average occupancy including leave for the period April 07 to Mar 08 was 127%. During the same period in 08 / 09, the average occupancy was 112%.

Minimise delayed transfers of care from OA inpatient beds to maximum of 7.5%.

While the target of 7.5% has not been achieved, the OA services managed to reduce the average level of delays over the course of the year to 16.6% at the end of March 09.

In addition, the trust’s Acute Care Forum had the following targets: Acute Care Forum targets Achievements

Establish a work plan for improvements in all areas of the four ‘must dos’ within all inpatient areas.

In place and progressing in each borough.

Introduce up to date ward information packs to be provided to all inpatients.

All wards have up to date information packs that are provided on admission to all inpatients.

Introduce staff picture boards on all wards.

Picture boards up in all acute wards giving information and identifying ward staff.

Ensure all service users are greeted and orientated on the wards upon admission and are provided with a toiletries pack.

In place in all boroughs.

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Acute Care Forum targets Achievements

Establish a 2 working day standard for all service users to be met by the Modern Matron upon admission.

Established and successfully highlighting areas for improvement and areas of good practice in all wards.

Introduction of the Dr Foster Patient Experience Tracker tool on all acute adult wards.

Successful implementation of PET gaining feedback regarding the four ‘must dos’ as well as patient feedback on safety and cleanliness on the wards.

Feedback has been overwhelmingly positive particularly regarding relationships and attitude of staff.

In relatively weaker areas regarding feedback on ward cleanliness action plans have been developed and more frequent checking and there has been a consistent improvement in scores.

2.6 Increase access to psychological therapies The importance of improving access to psychological therapies is a consistent message from our service users. The work programme is led by the trust Psychological Therapies Board and considerable progress has been made during the year. The creation of new posts has allowed more service users to receive evidence-based treatments based on NICE guidance. Particular attention was paid to the provision of cognitive behavioural therapy for psychosis, family therapy and services for people with a personality disorder. We have been successful in winning a bid for more psychological therapy in primary care in partnership with Greenwich Teaching Primary Care Trust. This will result in an additional 17 psychological therapists in a new base in Eltham, Greenwich. Psychological Therapies Achievements

Support the development of local bids for the new IAPT monies.

Bid submitted by each borough; successful in Greenwich.

Increase the number of psychological therapy posts by 14 wte across the trust.

Increase of 17 posts across the trust.

Increase the number of psychology graduates working as HCAs within inpatient care settings by 2 per directorate.

Achieved.

Establish a borough-based CBT-for-psychosis training and supervision programme

Ongoing.

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Psychological Therapies Achievements

Roll out a family-inclusive practice training programme across the service directorates.

Ongoing. A senior clinician has been seconded full-time to co-ordinate and deliver the training.

2.7 Implement evidence-based care pathways The trust Clinical Effectiveness Group (CEG) co-ordinates professional and service strategies to identify, monitor and report risks on clinical quality related to the four ‘must dos’ and priorities, the Healthcare Commission standards, the NHSLA requirements and the National Patient Survey. This has included the implementation of NICE technology appraisals and guidelines, the clinical audit program, clinical supervision and leadership, including the launch of the trust clinical supervision policy, carers support, and overseeing policy reviews, such as the revised clinical risk policy and the CPA policy. Other work priorities have included improving clinical coding, implementing MDT operational policies and caseload zoning, the provision of evidence based user and carer information, and development of the trust intranet to include comprehensive evidence for practice sections to support clinicians. Evidence-Based Care Pathways Achievements

Roll out community-based programmes for the management of people with personality disorders in at least one team in each borough.

Community-based personality disorder programmes have been launched in Bexley and Bromley. The work to quantify the need for PD services has progressed well with ICD coding and formulation of people with PD showing 23% on acute wards.

Establish the Personality Disorder Day Centre in the Bracton.

The William Morris PD Day Centre is now open.

Carry out a scoping review of the trust’s assessment and management of people with early-onset dementia and produce a clear set of recommendations.

The review’s recommendations have been considered by the Executive; action is taking place through the trust’s response to the Dementia strategy.

Develop and establish clear pathways for the assessment and management of dual diagnosis in each borough and the forensic directorate.

The Dual Diagnosis Strategy was launched in July 08 and work to implement and embed best-practice pathways is underway.

Every service user taking medication to have been offered information on medication choices, effects, side effects and physical monitoring.

Significant improvement in our score on this item in the National Patient Survey – this year 56% of service users surveyed said that they had been offered information compared with 42% last year. This took the trust above the comparator average of 54%.

Support the development of a This work is being taken forward via the trust Service Line

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Evidence-Based Care Pathways Achievements

common approach to the care of people on standard CPA, including the introduction of a stepped-care model for the treatment of depression.

Reporting Programme. The audit of the NICE depression guidelines is the priority across all care groups and an audit tool has been developed.

2.8 Implement the new mental health legislation Implementation of the MHA 2007 was overseen by the trust MHA Legislation Scrutiny Committee. The achievements went beyond implementing the changes to reviewing the systems and procedures for on-going compliance with legislation. Key achievements were: • Delivering mandatory training to over 95% of the staff identified by the training

needs analysis • Reviewing existing policies and procedures to reflect all areas on the policy

scoping plan published by CSIP • Carrying out Equality Impact Assessments for all policies • Reviewing and strengthening clinical systems through the implementation of new

standardised forms and guidance for the use of RiO, intelligent information reports reflecting the MHMDS changes for the Act and incorporating MHA issues in the trust audit plan

• Doubling the numbers of MHA Managers, enabling more timely Hearings and greater oversight through ward visits

• Informing users and carers about the changes and supporting service users to host a successful conference for World Mental Health Day on Advocacy

2.9 Develop the role of our governors and members During 08/09, our primary focus was on the development of the role of governors and members. Governors are actively involved in the trust’s Service User and Carer Council, trust Psychological Therapies Board and trust Social Inclusion steering group. The Council of Governors has a sub-committee on membership that supports members being involved in the annual planning process through hosting borough focus groups for members to comment on the proposed trust priorities. All Board away days are attended by 2 – 4 governors. The target to increase the trust membership by 5% was achieved within the first six months of the year and, by the end of the year, our membership had increased by 10% overall. We are working to increase our constituency of younger members (age 14 to 25). This work has been supported by governors undertaking a successful programme of awareness-raising visits to local schools during the year. At the start of the year, there were 97 young people in the public constituency and 44 in the service user/carer constituency; these figures increased to 208 and 51 respectively, an overall increase of 84%.

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March 2008 New Members March 2009 % Change Public (14 – 25) 97 111 208 +114% Service Users (14 – 25)

44 7 51 +16%

Total (14 – 25) 141 118 259 +84% Achievements made against our annual plan objectives are as follows: Governors and Members Achievements

Establish pre-Council informal meetings to feed back to governors and identify agenda items.

Achieved.

Increase trust membership by 5%.

Achieved – increased by 10%.

Expand the User & Carer Council to include governors.

Achieved.

Governors to undertake >3 visits during the year.

Governors have undertaken a successful programme of awareness-raising visits to local schools during the year.

2.10 Ensure excellence in leadership and management The results of the 2008 National Staff Survey were very positive. Oxleas had amongst the highest scores for mental health trusts in the country for: involvement of staff in the running of the trust; access to training; and overall work/life balance. Oxleas was in the top 20% for 21 of the categories and achieved the best score nationally, in 8 categories (see appendix ii). During 2008/09 we continued our focus on leadership development. We launched the Oxleas Leadership Programme in October 2007 and this course, jointly developed in collaboration with the University of Greenwich, was completed by a first cohort of thirty middle-managers and clinicians from across the trust in the summer of 2008. We also continued the roll-out of performance management training for team managers to improve the quality of management at all levels in the organisation. Excellence in Leadership & Management Achievements

Ensure that at least 80% of all trust managers have completed basic performance management training by the end of the year.

Achieved.

Complete and review the trust Leadership Programme with Greenwich University.

Achieved.

Reduce directorate The rolling average sickness-absence has been reduced by

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Excellence in Leadership & Management Achievements

sickness and absence by 1% from 1st April baseline.

0.7% (March 09 compared with March 08). However, the real decrease is likely to have been higher than this as the completeness of data is much improved following full roll-out of electronic reporting.

Ensure that 80% of all staff will have had a PDR during the year.

Further work is needed to simplify and improve reporting mechanisms. This will be taken forward in 09/10. Feedback from the 2008 National Staff Survey shows that two-thirds of staff stated that they had received a KSF appraisal; this score is in line with the national average.

2.11 Maintain our profile by developing new initiatives, increasing

marketing activity and participating in nationally recognised schemes

Oxleas is represented at senior level in several high-profile national and regional groups, including: • The National Acute Care Programme (Co-Chair) • The Darzi Clinical Care Pathways Review – London MH Group (Chair) • The Foundation Trust Network Mental Health Group (Chair) • Foundation Trust Network Board (member) • The MH Payment by Results Project Board, Expert Reference Panel and Costing

Groups • The London Currency Development Programme • The MH Standard Contract Reference Group • The London IAPT (Improving Access to Psychological Therapies) Programme • The MH NICE Guideline Review Group • The Royal College of Psychiatrist’s Leadership Group • The London Mental Health Trusts’ Chairs Group • The National Foundation Trusts’ Governance Board All of these opportunities have been used to drive forward innovation and service improvement within the trust. During the year, applications were submitted for a number of awards. • The Heath Clinic won the NHS London Health and Social Care Awards for

excellence in risk management and the trust was a finalist in the partnership working, people’s experience and improving access categories.

• Oxleas received an award for nursing/pharmacy medicines management in the National Prescribing Centre Awards.

• Oxleas’ information prescription and intranet project was a finalist in the national Health Service Journal Awards.

Maintaining our Profile Achievements

Support the submission of at least one application for a national award during the year.

The trust has made a number of applications for awards this year and the Heath Clinic won the NHS London Health and Social Care Awards for excellence in risk management.

Oxleas received an award for nursing/pharmacy medicines management in the National Prescribing Centre Awards.

Oxleas’ information prescription and intranet project was a

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Maintaining our Profile Achievements finalist in the national Health Service Journal awards.

Maintain leadership role in national initiatives.

Oxleas is represented at senior level in several national/London groups One of our clinical psychiatrists is on the national quality board as one of the 6 clinical experts

Expand the trust’s business (alone or with a partner) by at least one new initiative.

The trust has been asked to provide the Bexley community health services and has been short-listed in Bromley and Lewisham for the future provision of the borough’s community services.

Ensure that the directorates’ lean projects achieve their agreed outcomes / targets.

Six lean projects were launched; 5 have been completed:

• Efficiency of nursing handover and ward rounds

• Procurement processes

• Admission pathways

• Discharge processes

• Referral processes

Use the lean projects to promote Oxleas’ profile through at least one journal article and / or one conference presentation.

Conference presentation given by the Director of HR & OD.

Develop a directorate plan for the development of relationships with key partners

Achieved.

Develop a business case for the provision of residential care for working-age adults discharged from AMH services and those requiring forensic move-on.

A business case has been developed as per the target; a decision has not yet finally been taken as to whether to progress or not.

2.12 Ensuring our finances are robust Oxleas with external consultancy support, launched six lean pilot projects. Issues tackled included: • Efficiency of nursing handover and ward rounds; • Procurement processes; • Admission pathways; • Discharge processes; and • Referral processes. Results demonstrated that application of lean principles can significantly reduce waste and improve efficiency. Outcomes include: • Reduction of ward handover time by 30 minutes allowing increased training time

and time spent with service users • Streamlining of referrals and assessment processes for CAMHS reducing

timescales, creating extra capacity and improving usage of RiO

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• Streamlined admissions process for the Bracton centre that has allowed for external referrals to be admitted more speedily. This has helped the Bracton centre increase its income from external referrals.

The learning from these projects is being taken forward in inpatient wards using the nationally developed ‘Productive Ward’ programme.

Financial Robustness Achievements

Achieve the directorate target 1% CRE saving (including Bracton income target).

Achieved.

Reduce spend on nurse bank to within the cost of the nurse staffing establishment.

A significant reduction has taken place in bank costs. At year end in 07/08, the nursing budget was 3% overspent. The position for 08/09 as at the end of March 09 was an overspend of 0.3% for 2008/09.

Establish a regular reporting mechanism to monitor bank usage and expenditure closely.

Achieved.

Review estate costs with a view to saving 10% of £2.84m cost (£284k).

Achieved.

Deliver an £85k reduction in energy costs.

Achieved.

Achieve the cross-directorate target 0.8% CRE saving.

Not achieved.

Delivering recurrent cash-releasing efficiency (CRE) savings is crucial if the trust is to achieve its goal of continuing financial robustness and realise one of the key benefits of foundation trust status – reinvesting surpluses to improve services. The CRE target for 2008/09 was £1.8m. Of this £1.1m was planned at Directorate levels, and £0.7m for trust wide savings. During the year the directorate level savings were marginally over achieved, but the trust wide ones required more time to implement and achieve the levels required. Also, some of the plans were not considered expedient to continue within the light of changing circumstances and demand patterns. The savings achieved contributed to our overall financial results which showed that the EBITDA margin was slightly above the planned level and retained surplus before exceptional items was also higher than planned. We also achieved non-recurrent savings. Nurse Bank Expenditure During 2007/08, nurse bank expenditure represented one of the trust’s most significant cost pressures; a project was launched in 2008 to:

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• Review and re-launch the Temporary Staffing Policy to ensure that all staff were clear as to when temporary staff could and could not be booked;

• Ensure that the full benefits of the electronic booking system were being realised in terms of reporting bank activity and the reasons for it;

• Review the nursing establishments across our inpatient units to ensure that ward staffing budgets were adequate;

• Review the use of special observations across the trust’s inpatient units;

• Provide intensive HR support to wards with particularly high bank usage (e.g. management of long-term sickness, recruitment etc.)

This approach was demonstrably successful and nurse bank expenditure has reduced from an average of over £500,000 per month in 2007/08 to £450,000 per month in 2008/09. This is a reduction of £600,000 for the year. Nurse agency expenditure reduced for a second year and is now £7,000 spend per month. Estates Expenditure Approximately 10% of our cost base is attributable to our estate. A review was launched in summer 2007 and comprises three main elements:

(1) A review of trust property in use by others;

(2) An analysis of costs in use by the trust;

(3) The development of the trust Environmental Strategy.

Proposals for the rationalisation and reprovision of properties were drawn up as part of the review and these are considered as part of all service development plans. During 08/09, a saving of £284k was achieved in this way. We also implemented a number of additional measures to ensure that the trust meets high environmental standards and reduces its total energy consumption:

• A programme to introduce new high efficiency lighting was rolled out across trust sites and sensor switching for lights was installed as standard in meeting rooms, corridors, kitchens and stores.

• Gas and water consumption at all premises is now monitored to identify areas for reduction.

A saving of £85k was achieved through increased energy efficiency. 2.13 Improve data quality and the use of information across the

trust Developing the availability of useful and high quality data has been an important piece of work within 2008/9. Improve data quality Achievements

Establish regular benchmarking reports to help directorates to identify CRE saving opportunities.

Achieved.

Launch the service line reporting (SLR) projects in

Achieved.

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Improve data quality Achievements working age, older adult and forensic & challenging behaviour services.

Ensure that activity & KPI reports are reviewed as a routine part of directorate team meetings.

Achieved.

Ensure that all service users have recorded on RiO: a valid ethnic code; carer details; crisis plan; CPA level and care plan.

Partly achieved.

92% of all service users have a valid ethnic code.

99% of Enhanced CPA Service users have a care plan recorded on RiO and 94% have a crisis plan recorded on RiO.

19% of service users have a carer recorded on RiO.

Procure data warehouse / business intelligence system to facilitate the future development of service line reports.

A consultant has been commissioned and has undertaken preliminary scoping work in order for the Trust to make a decision regarding a tender.

At the beginning of last year, Oxleas led the development of a bid to NHS London for funding to support a programme involving all of London’s ten mental health trusts to develop and agree clinically meaningful units for mental health, allocation of costs to these units and a method for assessing services between trusts pan-London. The London programme has been recognised by the DH as an official development site within the national MH PbR programme and has set a target for the development of Mental Health currencies by March 2010. The following work has been undertaken to further improve our information systems: • Benchmarking Oxleas services: we developed a benchmarking profile of

services across all three boroughs. This work examined staffing costs and activity figures in order to enable us to assess variation between services. This has enabled the trust to set cross trust activity standards for different services to ensure improved efficiency.

• Data Quality Assurance: In 2008/9 we developed a more robust process to

ensure the quality of the clinical and activity data held on RiO. Data completeness and quality reports are circulated monthly to all trust teams for use within staff supervision and improvements are reported as part of our KPI reports. Data quality has significantly improved as ownership at a service level has increased.

• Activity and Board Reports: all directorates are provided with monthly activity

reports. This supports discussions and planning processes internally and with commissioners and enabled teams to monitor improvements to service delivery and PCTs to recognise the level of service provided by the trust. Activity, alongside trust and national KPIs is reported to the Board on a monthly basis.

• Business Intelligence System: to deliver more meaningful information we need

to be able to link different data together to create a more holistic picture of the

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way in which activity, staffing, finance and other variables impact on our service delivery and performance. In order to do this we are investigating the procurement of a Business Intelligence system. Work was completed in 2008/09 to develop a first stage business case and scope our requirements along with tender documentation to be reviewed and approved by the executive team and the board.

• RiO Version 5: during 2008/9, we continued to participate in the London wide

RiO development plans and will implement RiO version 5 in July 2009. Implementation of version 5 will ensure we are linked to the national spine.

2.14 Our financial performance 2.14.1 Monitor rating The following table shows the planned and actual risk rating for 2008/09: Metric Qtr 1 Qtr2 Qtr3 Qtr4 PlanEBITDA margin 3 3 3 3 3EBITDA % achieved 4 4 5 5 5ROA 5 5 5 5 4I&E Surplus margin 5 5 5 5 3Liquid ratio 5 5 5 5 5 4.4 4.4 4.5 4.5 3.9 The increase in the risk rating was due to better I&E surplus and ROA. 2.14.2 Income and expenditure: comparison of plan to actual performance Income 2008/09

Plan£.m

2008/09 Actual

£.m Income Clinical 124.6 126.7 Non-clinical 4.9 6.9 Total income 129.5 133.6 Expenditure Pay (88.3) (88.5) Non pay (33.0) (35.5) EBITDA 8.2 9.6 Exceptional items (3.9) (4.5) Depreciation (2.3) (2.2) Interest Receivable 0.9 1.4 Interest payable (0.6) (0.6) PDC Dividend (4.2) (4.2) Net Surplus / (Deficit) (1.9) (0.4) EBITDA (Earnings before interest, taxation, dividend and amortisation) was £9.62m (plan £8.16m) and was 7.1% of turnover (plan 6.3%). The surplus before exceptional items was £4.1m compared to the plan of £2.1m.

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After exceptional items (impairments of assets) the net deficit was £.37m (plan £1.86m deficit). The exceptional items were all related to asset values, and the main one was the impairment of the capital expenditure at Memorial Hospital. The main significant factors in these variations were: I&E variance

Reasons for variance In year management Future strategy

+£1.95m Cost & volume income due to high occupancy of Bracton (Medium Secure Unit) and risk share income from high expenditure on placements

- It is not planned that the income will be as high in future years.

-£1.35m Cost pressures on out of area placements due to high demand.

The trust was developing Home Treatment Teams to enable treatment locally in the community. Also intensive observations in our own wards were used to keep the costs as low as possible.

Further Home Treatment Team development within service directorate plans.

+£0.35m Drug costs were lower than plan due to increased use of generic drugs.

New drugs are likely to increase costs.

+£0.5m High cash balances and high interest rates to December 2008 resulted in a high level of interest received.

The trust will continue to maximise cash levels and invest in the best safe banks.

-£0.54m Higher than planned impairment costs

- -

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2.14.3 Cash flow: comparison of plan to actual performance Plan

£.mActual

£.m EBITDA 8.16 9.62 Movement in working capital: Debtors (5.00) (2.0) Stock - 0.1 Prepayments - (0.38) Creditors (5.67) (2.33) Accruals 1.35 Deferred income 0.52 Provision 0.65 Cash flow from operations (2.51) 9.24 Capital expenditure (9.40) (1.90) Receipts from sale of assets 0.3 Cash flow before financing (11.91) 7.37 Movement in long term creditors 0.05 0.02 Interest paid (0.61) (0.62) Interest received 0.92 1.46 Repayment of loans / leases (0.18) - Dividends paid (4.17) (4.17) Net cash (outflow) / inflow (15.90) 4.06 Opening Cash Balance 36.28 36.28 Closing Cash Balance 20.39 40.34 The plan was for cash to reduce from £36m to £20m. In the event there was a small increase to £40m. The main reasons for the high cash position are: • EBITDA was higher than planned by £1.4m • Better than expected cash flow from NHS commissioners that resulted in

continued low debtor levels. • There were very high creditors’ balances at the beginning of the year due to

payments to us in advance. Although there were not repeated, the creditor position remained higher than planned. This meant that the actual outflow was less than expected.

• Accruals increased, as did deferred income and provisions. • Capital expenditure was much lower. Some of this was due to a slippage in the

programme in order to save costs, and some was due to a high level of expenditure within the projects that was revenue in nature.

In 2009/10 we will plan for debtors to revert to more normal, higher, levels; capital spend will be higher; it is expected that interest rates will remain low for the year; creditors reduce; and EBITDA to be lower that the outturn in 2008/09. The result will be a reduced cash balance.

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2.14.4 Balance Sheet The comparison of planned and actual balance sheet is: As at 31st March 2009

Plan£.m

As at 31st March 2009Actual

£.mFixed assets 105.63 98.67Stock / debtors 7.07 3.23Cash 20.38 40.33Current liabilities (13.38) (19.37)Long term debtors - -Long term creditors (7.91) (8.08)Provisions (2.70) (3.36)Total Assets Employed 109.08 111.42Public Dividend Capital 67.28 67.28Income & Expenditure reserve 0.88 2.57Revaluation reserve 39.70 40.35Other 1.22 1.22Total Funds Employed 109.08 111.42 The trust undertook a revaluation at the end of 2008/09. This showed an overall reduction of £3.6m. This was made up of some increases in building values, reductions in land values and impairments on new buildings. The net result was a small increase in the revaluation reserve, and on impairment, (which is a charge to 1&E account) of £4.46m. This impairment resulted in a net retained deficit on the I&E account of £370,000 and so the I&E reserve was marginally lower than last year. This reserve is higher than planned due to the higher EBITDA. Debtors are higher than last year but still very low due to high liquidity in the commissioning PCTs. This low level cannot be relied on for the future so we will be planning for an increase. Current liabilities remain at the same level as last year, but this is higher than the planned level due to higher provisions. Cash balances are £4m higher than last year but considerably higher than planned as explained in the notes on the cash flow.

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3. Our Priorities and Plans for 2009/10 3.1 Summary of the planning process

PUR

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To improve lives by providing the best quality health and social care for our

service users and their carers.

User Focus

Excellence

Learning

Responsive

Partnership

Safety

Cash-releasing efficiency (CRE) programme.

Prior year performance

Regulatory framework

Demand analysis

Capacity analysisPEST analysis

Market & competitor analysis

Establish common care pathways across all trust services.

Promote social inclusion.

Promote clinical quality.

Efficient servicesExcellent quality services

Support families and carersProvide information for our service users and their carersEnhance care planningImprove the way we relate to service users and their carers

Increase access to psychologica therapies.

Provide community provider services.

Promote social inclusion for all our usersDeliver consistently excellent quality, safe and responsive services.Engage users, carers, public and partners in the governance and planning of our services.Develop a fully engaged, skilled and motivated workforce.Ensure value for money in all our services.

Deliver financial plan

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The diagram on the previous page summarises the process we went through as an organisation to identify our priority work streams for the year ahead:

(i) We considered our purpose and values and the internal and external contexts in which we will be operating during 2009/10. We identified drivers, opportunities and threats and reviewed our own organisational capacity and capability to manage these effectively.

(ii) We confirmed that our strategic objectives are still fit for purpose going forward into the new financial year.

(iii) We agreed five priority work streams for the next 12 months. The Membership Sub-Committee worked with the Board to ensure that members were meaningfully involved in the annual planning process. Governors from the sub-committee attended annual planning sessions at the quarterly trust Board away days and all members were invited to attend borough focus groups to comment on and contribute to our 09/10 plans. The following sections outline the work we did in relation to each of the above areas: Section 3.2 Reviewing prior year performance Section 3.3 Analysing the external environment PEST analysis Analysis of regulatory requirements and policy drivers for change Section 3.4 Market and competitor analysis Section 3.5 Review and forecast of activity and demand Section 3.6 Internal capacity Section 3.7 Priorities and plans – improving quality and our four ‘must dos’ Section 3.8 Priorities and plans – five priority work streams Section 3.9 Financial and investment implications of our plans Section 3.10 Financial forecast summary Section 3.11 Investment and disposal strategy Section 3.12 Finance and working capital strategy Section 3.13 Summary of key assumptions

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3.2 Reviewing prior year performance

• A review of the progress made against our key 2008/9 work streams (see sections 2.4 to 2.13);

• Identification of any work still to be done;

• Prioritisation of this work for 2009/10. The table below summarises the decisions:

2008/9 priority work stream

Continue as specific

09/10 priority work

streams?

Rationale

Four must dos YES

Significant achievements have been made in 2008/9 as evidenced by the improvements in our National Patient Survey results. Members felt that the four must dos had delivered improvements. Feedback was clear that focus on these areas was still appropriate and should continue.

1.

Promote social inclusion YES

Achievements have been made in 2008/9, however, there is still significant ongoing work to be done. Improving social inclusion for service users is of huge importance in promoting recovery and avoiding relapse and supports service users and carers to integrate fully into the community. In 2009/10, we will focus on employment and meaningful day opportunities for service users.

2. Ensure our finances are robust

NO This is felt to be part of our core mainstream business.

3.

Increase access to psychological therapies

YES

Although improvements have been made in 2008/9 there are still large numbers of patients who do not receive a psychological therapies service or who have to wait a long time for access. We will also include the partnership work we are undertaking with Greenwich PCT to deliver IAPT services.

4.

Implement evidence-based care pathways

YES – in part

We need to ensure that our own care pathways are developed in line with best clinical practice, meet quality standards and fit with the development of national currencies. It is important that we maintain this work stream as critical to the trust’s development in 2009/10.

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2008/9 priority work stream

Continue as specific

09/10 priority work

streams?

Rationale

5. Maintain our profile by developing new initiatives, increasing marketing activity and participating in nationally recognised schemes.

YES – in part

Oxleas has been at the forefront of national and local initiatives in 2008/9 and is a member of many key national and local forums. In 2009/10 we will be taking forward a due diligence process in relation to the delivery of Bexley community provider services and may be undertaking work to provide like services for Bromley and Lewisham. These initiatives will significantly increase our services within the next year.

6. Develop the role of our governors and members.

NO Work will continue in 2009/10 but not as a priority work stream.

7. Improve the delivery of acute and crisis care.

YES – four ‘must dos’

In 2009/10 our critical work streams will include work to improve acute and crisis care under a wider remit of improving quality.

8. Ensure excellence in leadership and management

NO

Will be led by the HR & Organisational Development Directorate within their directorate annual plan.

9. Improve data quality and the use of information across the trust

NO

Improvement of information and data will form part of the work required to underpin each priority work stream rather than being a work stream within its own right.

10. Implement the new mental health legislation

NO

Work will continue to develop our processes and compliance in line with partner agencies, however, in 2009/10 this will no longer be a priority work stream.

Item 10 ‘Implement the new mental health legislation’ was time limited as a critical work stream. Post implementation this has become part of our mainstream business. Items 2, 6, 8 and 9 retain their importance as vital elements of our overall performance. These will be continued as part of mainstream business which will continue to be monitored by the Board. 3.3 Analysing the external environment 3.3.1 PEST analysis The tables below summarise:

• The ‘PEST’ factors identified;

• The potential implications of each one;

• How we plan to address these implications.

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Political Factors Implications Addressed by:

Publication of ‘A Framework for Action’

• Increased expectations regarding early intervention and services for early-onset dementia.

• Mental health care pathways to be clearly defined.

• Opportunities to be become involved in polyclinics.

• Will develop a trust response to the new Dementia Strategy

• Involvement in the pan London DH SLR and PbR projects in 2009/10.

• Through provision of community provider services alongside mental health and learning disability services we will be in a better position to contribute to the development of polyclinics

Publication of the NHS Next Stage Review

• Establishing a quality report within our Annual Report

• Introducing patient reported outcome measures (PROMS) as quality measures within quality report

• Implementation of a quality incentive system, ‘CQUIN’

• Ability to monitor clinical quality is a key component of the responsibilities of trust boards via a quality dashboard

• Implication of the NHS Constitution

• A Quality Report for 2008/9 has been developed utilising progress against our four ’must dos’ and linking quality indicators from our quality and safety improvement plan

• Roll out of the Patient Experience Tracker to provide PROMS is part of our four ‘must dos’ work programme in 2009/10

• Our quality and safety improvement plan as part of our 2009/10 contract has been devised in a way to support CQUIN in 2010/11

• Our work to promote clinical quality requires more appropriate structures to govern quality within the trust and the development of a clinical dashboard

‘A Picture of Health’

• Period of substantial upheaval – commissioners unlikely to focus on mental health; new large South London NHS trust may shift the balance of power.

• Decision to reduce services on the site of Queen Mary’s Hospital will enable the development of a Bexley Health Campus.

• By providing community provider services we will become a larger provider of healthcare services and have a greater ability to work with commissioners and partners on delivering local priorities, including more out of hospital care

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World class commissioning

• Increased focus on choice and personalisation

• Increased emphasis on care pathways.

• Diversity of providers – growth of the third sector and market management by commissioners.

• Externalisation of local PCT provider-arms.

• Our priority work stream establishing common care pathways ensures we are linked in to national work on developing care pathways through SLR and linked to national currencies; this work will also support the local development of the personalisation agenda

• Our priority work stream to ‘provide community provider services’ takes advantage of opportunities to support successful externalisation of PCT provider services

Standard contract for mental health services.

• Introduction of host commissioning arrangements – could strengthen commissioning or make even more complex.

• New requirements for Quality and Safety Improvement and Data Quality Improvement Plans.

• Our quality & safety improvement and data quality improvement plans directly link into our four ‘must dos’ and trust wide quality agenda which will be monitored on a quarterly basis and utilised to report in our 2009/10 quality report

Comprehensive Spending Review – new PSA targets

• Requirements for information against the PSAs

• These targets are linked into our cost releasing efficiency plans and the data quality and collection requirements underpin all of our work streams

IAPT • Opportunities to develop psychological therapies provision across our three boroughs.

• In Greenwich, we have been chosen to manage the provision of the primary care IAPT service

• The trust priority work stream to increase access to psychological therapies will increase our ability to support services in our other two boroughs when the opportunity arises.

The ‘Fit for Work’ and ‘Pathways to Work’ programmes.

• Opportunities to increase employment-related support to our service users.

• Scope to link these programmes with IAPT services.

• This work will be led by our new Head of Social Inclusion

Increasingly • We must ensure equal • The trust picks this work up through

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diverse population & workforce.

access and culturally sensitive services re staff and service users.

on-going commitment within to our equality and diversity strategy

Economic Factors

Implications Addressed by:

Economic situation

• There is unlikely to be new significant investment in the short term, and possible reductions in the medium term.

• Income receivable will be reduced due to lower interest rates.

• The trust has a series of cash releasing efficiency plans to cover the efficiency requirements for 2009/10. The trust is only relying on a small increase in income that has already been agreed.

• Mitigation plans have been developed if there are significant income cuts.

Service Line Reporting

• We will need to invest in a data warehouse / business intelligence system.

• The common care pathways work stream picks up our involvement in the national PbR and SLR projects.

• We are presently preparing the business case for a business intelligence system.

Payment by Results for mental health services

• We will need appropriate information and costing systems.

• There will be an income risk related to our current costs.

• The data warehouse / business intelligence system will be specified to cover our requirements.

• The trust’s Reference Cost index has continued to reduce and is now at 89%. This plus our mix of inpatient and community services, would indicate that this is a low risk.

• The trust will be undertaking costing for PbR as soon as the currencies are agreed.

Local Health Economy

• There are continued pressures in the local economy with particular emphasis on the local acute provider. The PCT’s are in an improving position, but finance continues to be tight.

• We have agreed the contracts for 2009/10 with some minor income increases along with some movement away from variable income to more secure block income.

Corporation tax • Reduction in net income

• The trust has no private patient income.

• Most of our trading income relates to

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Economic Factors

Implications Addressed by:

patient occupational activity (such as cafes and horticulture). These do not give rise to taxable profits.

• The main risk related to tax on interest receivable and to-date this appears to be excluded.

IFRS • New accounting standards may alter our EBTIDA / surplus, Monitor risk ratings and Presidential Borrowing Limit.

• The audited work undertaken shows a very marginal change.

Social Factors Implications Addressed by:

Public discourse on healthy lifestyles.

• Increased focus on employer responsibility to promote healthy lifestyles.

• The HR and Organisational Development Directorate plans for 2009/10 pick up our commitments to promote healthy lifestyles for our staff

• Our quality and safety improvement plan for 09/10 has a focus on healthy lifestyles in the work we undertake with service users

Impact of the sustainability agenda.

• Increased expectation that large organisations should make active efforts to reduce their carbon footprint.

• Our estates review processes ensure we are reducing our carbon footprint via energy saving measures and recycling

Increased unemployment

• Potential increase in referrals

• Impact on existing service users

• The key focus of our ‘Promoting Social Inclusion’ priority work stream for 2009/10 is employment

Impact of growing numbers needing social housing

• May impact on delayed discharges and generally, on supporting service users in housing

• Evidence in 2008/9 has shown that there has not been an impact on delayed discharges and therefore this is currently not a key issue within our plans. This will be monitored through our monitoring of the delayed discharge target and would be addressed should the situation change

New disability assessment

• Process may disadvantage our service users

• At present this is not a key issue, this will be incorporated into our plans should the situation change

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Social Factors Implications Addressed by:

Safeguarding Children

• Increased focus on organisational and individual responsibilities to safeguard children

• Within the Nursing and Governance plans 2009/10 objectives have been set to ensure we meet all of our safeguarding children obligations (appendix xi)

• Increased training in safeguarding children

• Reviewing the capacity of the named doctor role

Technical Factors Implications Addressed by:

Increased range of communications media and growth of telecare

• Opportunity to provide information for service users and carers in innovative and more accessible ways.

• Potential to reduce admin burden.

• Could develop remote access or operating.

• Risk re data security.

• Development of a new trust website to be launched in July 2009

• Pilot of telemedicine in partnership with the University of Canterbury within the Bexley Directorate annual plan

Progressing the MHA, plus Mental Capacity Act and Deprivation of Liberties

• Capacity risks of implementation.

• Systems are already well established to ensure our compliance with legislation and the MHA group will take forward any necessary issues as required.

New CPA • Capacity risks of implementation.

• We have established a New CPA Implementation Board to take forward the work required to comply. This will fall under the remit of the work stream to promote clinical quality

National dementia Strategy

• Raised awareness and changing demography could increase referrals

• A trust response will be put in place through the Executive.

NICE Guidance • Risks of implementing Guidance without additional resources.

• NICE guidance and implementation will be picked up through our Clinical Effectiveness Group.

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3.3.2 Regulatory Requirements The sections that follow detail the regulatory frameworks for the year ahead and how we have ensured that the key areas of focus will be picked up through our existing governance structures or priority work streams.

New Requirements Implications Addressed by: In order to achieve a financial risk score of 5 trusts must now demonstrate 60 days of liquidity.

If we are to maintain our low risk for finance we will need to demonstrate a liquidity position of 60 days.

The current position is in excess of 90 days and the plans show that over 60 days will apply.

IFRS New accounting standards may alter our risk rating and Prudential Borrowing Limit.

The audited work shows that the effect on both Balance Sheet and I&E Account is very marginal.

3.3.2.1The Care Quality Commission The Care Quality Commission (CQC) took over from the Healthcare Commission on 1 April 2009. It is now a legal requirement that all trusts that provide NHS healthcare directly to patients are registered with the CQC. The CQC is expected to bring increased focus on safety outcomes and plans to work with the National Patient Safety Agency to determine levels of risk. National targets for 2008/9 were a single set of 14 indicators for mental health trusts and 4 for learning disability trusts. In March 2009, the HCC announced how these indicators would be constructed and we have ensured all information has been provided to allow appropriate review of our performance. Mental Health Indicators 2008/9 Health and wellbeing

Data Quality on Ethnic Group

Patterns of care from Mental Health Minimum Data Set (MHMDS) Completeness of the MHMDS Access to Crisis Resolution Home Treatment (CRHT)

Clinical Quality

Child and adolescent mental health services (CAMHS) Safety Care programme approach (CPA) 7 day follow up

Delayed transfers of care Best practice in mental health services for people with a learning disability (Green light toolkit) Experience of patients (one domain) Numbers of drug misusers in effective treatment

Patient focus and access

NHS staff satisfaction

Learning Disability Indicators 2008/9 Campus Provision Data quality on ethnic group Delayed transfers of care Number of people with care plans In 2009/10, we will continue to ensure that we can self certify compliance on these indicators and work with the CQC to ensure compliance with any changes to requirements.

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3.3.2.2 Monitor Monitor has updated the Compliance Framework for 2009/10 and updated guidance on annual plan and annual report requirements. All NHS Foundation trust boards are required to define their quality objectives and track performance based on clearly identified performance metrics. The main changes to Monitor requirements within the Compliance Framework 2009/10 is outlined in the table below:

Compliance Framework 2009/10 – Requirements New Requirements Implications Addressed by Boards must describe their objectives for improving quality

• Quality objectives need to be set out within our annual plan and communicated to the public within our annual report

• Quality objectives, approved by the Board are set out within our four ‘must do’ work streams and our quality and safety improvement plan (appendix iii)

• These quality objectives and progress will be available to the public within our annual report 2008/9 in the form of quality report (as required)

Boards must identify measurable performance metrics to monitor quality in terms of clinical outcomes, patient safety, patient experience

• Within the FreM we are required to produce quality report containing a set of quality indicators within our 2008/9 annual report

• Our quality report 2008/9 demonstrate performance against our annual plan four ‘must dos’ and indicators within our quality and safety improvement plan. These provide the required metrics for the board to monitor quality through quarterly reports.

Boards must ensure they have systems in place to improve quality, including meeting their own objectives, healthcare targets, national core standards and complying with all relevant legislation and understand and mitigate against risks

• All quality objectives local and national must be addressed and met in line with legislation

• Systems are in place to ensure monthly KPI reports include quality metrics and quarterly quality reports are delivered to the board

• We are currently in the process of redesigning our quality governance structures in order to ensure more robust structures and systems for monitoring quality are in place for 2009/10 as part of our ‘Promoting clinical quality’ work stream

Boards must self certify within the Annual Planning process registration with the Care Quality Commission & assessment that compliance will be ongoing

• Self certification required within our 2009/10 annual plan and registration with the CQC

• We have registered with the CQC and the annual plan has been approved by the Board on 7th May 2009 and statements agreed concerning compliance

In order to achieve a financial risk score of 5 trusts must now demonstrate 60 days of liquidity

• If we are to maintain our low risk rating for finance we will need to demonstrate a liquidity position of 60 days

• Our liquidity is in excess of 60 days

Membership reports must include

• Governor election turnout rates must be

• Governor election turnout rates can be found as required in

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information regarding governor election turn out rates

monitored and reported on within our Annual Plan 2009/10

section 6 of our annual plan

In assessing compliance with national targets Monitor will no longer use general rounding principles

• We must demonstrate that we meet or achieve above all targets to ensure compliance

• All monitor targets are contained within our trust monthly KPI report. Compliance will be reported based on the same measures as Monitor

Private Patient Cap • The trust has a ‘nil’ private patients cap

N/A

3.3.2.3 Public Service Agreements (PSA) Targets: 2008 – 2011 The Government’s Comprehensive Spending Reviews set three-year Departmental Expenditure Limits and, through Public Service Agreements (PSA), defined the key improvements that the public can expect from these resources. The following PSA targets are relevant to the trust in the year ahead:

PSA Target Addressed by Maximise employment opportunity

The trust wide priority work stream ‘Promoting Social Inclusion’. This work stream contains specific aims to support service users into employment including opportunities within and external to the trust.

Improve the health and wellbeing of children and young people

This will be picked up through the annual plan specific to the CAMHS directorate (see appendix xi).

Address disadvantage The trust wide priority work stream ‘Promoting Social Inclusion’ and continued promotion throughout all services regarding recovery and independent living will address disadvantage.

Increase the proportion of socially excluded adults in settled accommodation, education or training

The trust wide priority work stream ‘Promoting Social Inclusion’ contains specific aims to support service users into training and education and identify service users requiring support to gain settled accommodation.

Tackle poverty and promote greater independence and wellbeing in later life

Supporting older adults to live independently at home within our older adults services.

Promote better health and wellbeing

The trust wide priority work stream ‘Promoting access to psychological therapies’

Ensure better care for all Improving self reporting experience of users and carers through the continued use of PET.

3.3.2.4 Darzi Review Darzi’s High Quality Care for All was published in June 2008 and forms the basis for the requirements regarding quality. The overriding message from Darzi’s work and David Nicholson’s follow up letter, Measuring for Quality Improvement (18 Nov 08), is that CQUIN, quality and safety improvement plans, quality report and clinical dashboards should be brought together in a common framework that is totally focused on quality. Requirements concerning quality have been identified by Monitor and the Care Quality Commission as previously highlighted and within the standard mental health contract requirements and NHS Operating Framework as described in the following sections.

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3.3.2.5 Standard Mental Health Contract During 2008/9, Oxleas has been involved in a national DH initiative to develop a standard contract for mental health services. It has been mandated that in 2009/10 all trusts must either use the new national standard contract or, if continuing with their current framework must include a number of extra mandated sections. We have chosen to maintain our own contracting framework as agreed with our commissioners including the new contact sections. The new mandated sections have been addressed in the following ways:

Mental Health Contracts 2009/10 – Requirements Area New Requirement Addressed by

Quality Quality and safety improvement plan comprising of: • Four nationally mandated

quality standards • Locally agreed quality

standards agreed with local commissioners

Our 2009/10 contract contains a quality and safety improvement plan (Q&SI Plan) including: • 4 mandatory quality standards • 7 locally agreed quality standards • 3 forensic specific quality standards (appendix iii)

Clinical Quality Review Process

Quarterly clinical quality review meetings between PCT and provider

Quarterly clinical quality review meetings have been set up with PEC Chairs to review progress against the Q&SI Plan. All standards in the plan have been set measurable indicators to demonstrate compliance that will be reported within a Quality Report on a quarterly basis.

Data Quality Data quality improvement plan The 2009/10 contract contains a data quality improvement plan including: • Further information requirements

regarding activity to be reported on a monthly basis

• A data development plan to improve data to monitor service quality

3.3.2.6 The NHS Operating Framework In 2009/10, the NHS priorities and ‘vital signs’ for trusts remain the same as those set in 2008/9; the overall aim remains systematically to deliver improvements to quality based on local needs. The key requirements in 2009/10 are to: • Continue to deliver against the national priorities and vital signs set in 2008/9

(within an updated performance management approach) • Prepare for a tighter financial climate in 2010/11 by investing wisely in 2009/10

and ensuring a solid financial foundation for efficient delivery of high quality services

• Put in place the required systems, planning processes and partnerships to ensure quality is at the heart of what we do

• Support and enable future large scale transformation to delivery high quality care by ensuring appropriate evidence based ways of working and leadership are in embedded within our organisation

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• Embed the three quality domains and four principles of delivering change to support further development of high quality care as laid out in High Quality Care for All

The table below identifies the vital signs and existing commitments that are relevant for mental health and learning disability provider trusts and shows how we will address each of the relevant indicators.

Existing Commitments Addressed by:

Deliver 7,500 new cases of psychosis served by early intervention teams per year.

All patients who need them to have access to crisis services with delivery of 100,000 new crisis resolution home treatment episodes each year.

All patients who need them to have access to a comprehensive child and adolescent mental health service, including 24-hour cover / appropriate services for 16 and 17 year olds and appropriate services for children and young people with learning disabilities.

Delayed transfers of care to be maintained at a minimum level

Systems already in place to deliver target requirements in line with local commissioning agreements.

National Requirements Addressed by:

MRSA number of infections.

Rates of Clostridium difficile.

Existing governance group – infection control (reported within our Quality Report)

National Priorities for Local Delivery Addressed by:

Suicide and injury of undetermined intent mortality rate.

Effectiveness of child and adolescent mental health service (comprehensive CAMHS).

Self-reported experience of patients and users.

NHS staff survey scores-based measures of job satisfaction.

Clinical Effectiveness Group

CAMHS service plans

The ‘Must Do’ priorities

Workforce Development Group

Local Action Addressed by:

Achievement of CNST risk management standards.

Proportion of people with depression and / or anxiety disorders who are offered psychological therapies.

Proportion of adults (18 and over) supported directly through social care to live independently at home.

Proportion of adults with learning disabilities in settled accommodation.

Proportion of adults in contact with secondary mental health services in settled accommodation.

Proportion of adults with learning disabilities in employment.

Patient-reported unmet care needs.

Number of delayed transfers of care per 100,000 population (aged 18 and over).

Clinical Effectiveness Group

The ‘must do’ priorities

Priority work streams:

Improve access to psychological therapies

Establish common care pathways

Promote social inclusion

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Timeliness of social care assessment.

Timeliness of social care packages.

Adults and older people receiving direct payments and / or individual budgets per 100,000 population (aged 18 and over).

Proportion of carers receiving a ‘carer’s break’ or a specific service for carers as a percentage of clients receiving community-based services.

Prescribing indicator (to be developed)

Learning disabilities

Patient and user-reported measure of respect and dignity in their treatment.

The Operating Framework also outlines a timeline for various national requirements in 2009/10. Those of key importance relate to the provision of PCT community provider services. We will ensure that our work stream to provide community services takes into account the following: June 2009: Quality framework for community services will be piloted (we will need to ensure our plans include delivery of the new quality framework for these services) October 2009: PCTs must have developed plans for future provision of community services. 3.3.2.7 Complaints and Incidents From 1 April 2009, the reform to NHS complaints system will come into effect, introducing a common process for all health and local authority adult social care services in England. One of the key changes is the removal of the 2nd stage review by the Healthcare Commission. In future, a complainant who is unhappy with the trust’s endeavours at local resolution can go directly to the Health Service Ombudsman to review the case. The new regulations require trusts to demonstrate compliance with the Parliamentary and Health Service Ombudsman’s Principles of Remedy and Administration when responding to complaints. Monitoring arrangements The trust will be required to provide an annual report to the PCT(s) and an anonymised version of the annual report must be made available to the public. In addition, the new Care Quality Commission regulatory framework will include a registration requirement relating to complaints. We will have to ensure that: • People, their relatives and carers are aware of and can use, with support where

needed, and without prejudice to their care and treatment, simple and clear arrangements for handling comments and complaints.

• Complaints about failures to ensure people’s health, safety and welfare are investigated and resolved promptly and effectively

• Learning from complaints is included in management and governance arrangements.

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Implications for the trust The focus over the last 18 months has been to deliver improvements in the complaints process, the standards of investigation and in learning from complaints. Improvements have been realised through focusing on time-scales, providing new training and introducing a new complaints report to the Patient Experience Group. The National Audit Office Report of October 2008 ‘Feeding back? Learning from complaints handling in health and social care’ showed that the trust has performed well in comparison with other trusts, especially with regard to the number of complaints referred back for further action by the Healthcare Commission. However improvements are required for the trust to comply with the new regulations; these include:

• Revising the complaints policy, guidance and publicity materials by the beginning of April

• Ensuring customer care training for front line staff dealing with concerns/ complaints.

• Increased input at initial stages of the complaint to ensure direct contact with each complainant to discuss the complaint and expected outcomes. The Early Adopter sites report significant impact on capacity.

• Expectation of greater flexibility in responding to a complaint, including o Conciliation services. o Increase in 2nd opinions both internal and external. o Appeal Panel –independent review of our complaints handling before

complaint goes to the Ombudsman. o Redress – policy needs to be developed.

• Learning from complaints. Investigation reports do not regularly include action plans to address upheld complaints. This will be addressed in the next round of investigation skills training and through the Investigation Guidance Pack. Improvements are also required in the monitoring and reporting of service improvements resulting from complaints.

The implementation of this work will be overseen by our Patient Experience Group. 3.4 Market and Competitor Analysis The NHS healthcare market is developing as Government policy to create plurality of providers is rolled out. Foundation trusts are in a good position to take advantage of the opportunities created by this. Oxleas aims to maximise these opportunities through: • Understanding and responding to the needs of commissioners, our stakeholders

and our local economy • Developing strong and effective partnerships with local statutory and third sector

partners We continue to enjoy good working relationships in the voluntary sector in each of our boroughs and have developed our Council of Governors to strengthen our relationships with local organisations.

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Intensity of rivalry Existing healthcare organisations (NHS and non-NHS) providing mental health services likely to become more competitive with each other World Class Commissioning/FT structure/PCT portal creates greater opportunities for competition and movement across geographical/service boundaries. However, lack of PbR structure in MH reduces ability for £ to follow patient. Reduction in use of specialist services such as forensic have led to private sector price reductions Opportunities may arise over trusts unable to achieve FT status

Threat of new entrants Private sector organisations both within UK and overseas able to provide NHS branded services. However, economic downturn may lead to less risk-taking in this area. Third sector – Govt encouragement of voluntary/social enterprise models

Threat of substitutes Greater focus could be given to primary care/preventative services Alternative care pathways could be developed reducing pathway into secondary care

Bargaining power of commissionersWorld Class Commissioning promotes diverse and competitive markets. Choose and Book develops mechanism for individual choice. Standards for quality, patient satisfaction and patient choice increasing More powerful, specialist commissioners being developed

Bargaining power of suppliers

Mental health services highly dependent on clinical staff – increasing competition to attract best staff in scarce professions Increasing use of technology for patient records/data analysis. Risk of becoming susceptible to increasing prices from key suppliers. Reduced prices in private sector

Competitive environment analysis

New Markets The trust has continued to develop its focus on marketing and has a well-established marketing group chaired by a non-executive director. We have developed our ‘horizon scanning’ capacity to ensure we identify opportunities and have established a robust system to assess the viability and desirability of pursuing new developments. As part of developing our business case for the integration of Bexley community services, we will be undertaking a full analysis of the community service market. This will include: • Opportunities for providing out of hospital care in line with local commissioning

intentions and Healthcare for London strategy. • Reviewing plans of practice based commissioners and how to better meet the

needs of primary care providers. • Opportunities arising from ‘A Picture of Health’ decision to reconfigure Queen

Mary’s hospital and create a Bexley health campus on the site. Two new prisons will also be built on the site of HMP Belmarsh and we intend to submit bids to be a provider of healthcare services for these new prisons in the future.

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3.5 Review of activity and demand Although we are involved in the development of PbR for Mental Health, and therefore in future will have clear currencies for activity to be monitored against we currently continue to monitor activity through the following indicators: Working Age Adult CMHTs:

Working Age Adult CMHT Caseloads (longer-term care)

0100200300400500600700800900

1000

Apr-08

M ay-08

Jun-08

Jul-08

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

M ar-09

Total Caseload Bexley Total Caseload Bromley Total Caseload Greenwich

Working Age Adult CMHT Caseloads (short-term care)

0200400600800

10001200140016001800

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

Total Caseload Bexley Total Caseload Bromley Total Caseload Greenwich

Older Adult CMHTs

Older Adult CMHT Caseloads

0200400600800

100012001400160018002000

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

Total Caseload Bexley Total Caseload Bromley Total Caseload

Commentary: The increase in caseload for more complex clients and reduction in the short term caseloads in Bexley and Bromley is a result of a renewed focus on ensuring service users are appropriately allocated to receive New CPA level care plans in future. The reduction in the Older Adult CMHT caseloads in Bexley and Bromley is a recording issue due to an amalgamation of teams resulting in the requirement to move caseload information on our RiO system. The teams have also been ensuring that during these moves service users who no longer require our services are discharged appropriately.

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Working Age Adult Admissions and Occupancy:

Admissions to acute inpatient beds (Working Age Adults)

0

50

100

150

200

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

Bexley Bromley Greenwich Total Linear (Total)

Bed Occupancy - Acute Working Age Adults (excluding leave)

60%

70%

80%

90%

100%

110%

120%

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

Bexley Bromley Greenwich Total Linear (Total)

Older Adult Admissions and Occupancy:

Admissions to acute inpatient beds (Older Adults)

0

10

20

30

40

50

Apr-08

M ay-08

Jun-08

Jul-08

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

M ar-09

Bexley Bromley Greenwich Total

Bed Occupancy - Older Adults (excluding leave)

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

Bexley Bromley Greenwich Occupancy total excluding leave

Commentary: The overall level of admissions has remained similar throughout the year. Occupancy levels have reduced in all units for working age adults as a concerted effort has been made in line with our annual plan targets.

Commentary: Overall numbers of older adult admissions have increased slightly. The peak in Oct – Dec was caused by different processes at local acute hospitals which have been resolved. The decrease in bed occupancy in Greenwich has led to the reduction in beds on Shepherdleas ward and reinvestment in community services (see schedule 2)

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Length of Stay WAA Wards - LOS Bandings (Trimmed 1-90 days)

0100200300400500600700800900

Bexley Total Bromley Total Greenwich Total Trust Total

1 - 7 Days 8 - 30 Days 31 - 60 Days 61 - 90 Days

OA Wards - LOS Bandings (Trimmed 1-120 days)

0

20

40

60

80

100

120

Bexley Total Bromley Total Greenwich Total Trust Total

1 - 7 Days 8 - 30 Days 31 - 60 Days 61 - 90 Days 91 - 120 Days

Crisis Home Treatment Team Episodes

Episodes of Crisis Care for Working Age Adult compared with Borough targets

0100200300400500600700800900

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

Bexley Actual Bexley Target Bromley ActualBromley Target Greenwich Actual Greenwich Target

Commentary: Trend in length of stay is similar for working age adults across all directorates with the majority staying between 7-30 days. For older adult wards length of stay trends in different units vary significantly and this is being reviewed. Length of stay in Greenwich has decreased and allowed the closure of some beds (see schedule 2)

Commentary: The target number of episodes of crisis supported by community and home treatment teams has been significantly overachieved in Bromley and Greenwich demonstrating the positive use of home treatment and crisis support to avoid admissions. Bexley has just achieved the target.Greenwich PCT has recognised the work undertaken by the crisis team and has invested further funds in 2009/10 in order to support this team to continue to deliver the high level of service.

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Child and Adolescent Mental Health Services

CAMHS Referrals received

020406080

100120140160180

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

Bexley Bromley Greenwich

CAMHS Caseload

600

720

840

960

1080

1200

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09


Adult Learning Disability Services

Adult Learning Disability Referrals

01020304050607080

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09


Adult Learning Disabilities Caseloads

0200400600800

1000120014001600

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09


Commentary: Referral rates in CAMHS are influenced by school holidays therefore creating peaks and troughs throughout the year. The caseloads of our three CAMHS teams remain similar throughout the year although there are variations in month due to administration.

Commentary: Referral numbers change month on month, partly due to administration processes which require improvement and partly as numbers are low. Caseloads for ALD have not changed significantly within the year other than a process of cleansing the caseloads on our system mid year.

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External Placements (Cost per Case) Forensic and Challenging Behaviour external placements

2007/08 Cumulative Bed Days 2008/09 Cumulative Bed Days Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4 Bexley 763 1,877 2,908 4,073 1,249 2,549 3,837 5,081Bromley 1181 2,478 3,756 4,591 845 1,722 2,532 3,252Greenwich 2002 3,930 5,588 6,961 1,234 2,485 3,707 4,877Oxleas 3946 8285 12252 15625 3328 6756 10076 13210

CAMHS external placements

2008/09 Cumulative Bed Days Q 1 Q 2 Q 3 Q 4 Bexley 494 959 1332 1764Bromley 418 768 1134 1565Greenwich 260 459 743 1046Oxleas 1172 2186 3209 4375

ALD external placements

2008/09 Cumulative Bed Days Q1 Q2 Q3 Q4 Greenwich 715 1409 2230 3040

Commentary: Forensic and Challenging Behaviour: Overall there has been a reduction in the use of forensic and challenging behaviour beds outside the trust by 15%. Greenwich and Bromley have both experienced a 30% reduction in bed days required externally, partly due to the use of new trust challenging behaviour beds and partly due to more robust monitoring processes for returning clients to Oxleas beds when appropriate. Unfortunately Bexley has seen an increase in demand by 24% in year. All three main commissioners have commissioned extra beds within our Forensic and challenging behaviour services for 2009/10 to support a reduction in external placements. Cross trust work will be taking place in 2009/10 to share best practice across boroughs and work towards reducing external placements further, especially in Bexley. CAMHS: Although the CAMHS requirement for external placements is steady throughout the year, this is higher than last year. There have been significant increases in demand from Bexley for young girls with personality disorders over the last two years. We are therefore working with Bexley Care Trust and Social Care on a business case to develop intensive young people outreach services in Bexley which could support these service users in the community and avoid admissions. ALD: Greenwich is the only borough for whom we hold the budget for external ALD placements. Our inpatient ALD unit (Atlas House) is an assessment and treatment unit and not intended for long stay, therefore when a service user is assessed as requiring long term health care support we are required to place them externally to the trust. This is being looked into by the CAMHS and ALD directorate.

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3.6 Our internal capacity Each year, the Board undertakes a self-assessment of the organisation’s strengths and weaknesses. Strengths

Strength How will we harness this? Link to Work stream(s) Continuing financial security.

• Continue the Opportunity Fund for Innovation.

• Make the most from local opportunities to expand.

• Cost releasing efficiencies programme

• Provide Community Provider services

Supportive and innovative senior clinicians who share the trust’s strategic aims and aspirations.

• Continue format of quarterly Board away days.

• Implement the findings of the Clinical review

• Support the Senior Clinical Practitioner Forum.

• Support senior clinicians in London SLR programme.

• Support staff through IT (e.g., blackberries)

• Promote clinical quality

• Establish common care pathways across all trust services

Positive staff culture (as demonstrated by the National Staff Survey findings).

• Continue to seek feedback from staff as to how we might best embed the trust’s values.

• Ensure that our ‘must dos’ are delivered.

• Develop incentive and reward schemes for staff.

• Encourage staff governors to take an active role in some of our critical work streams.

• Practice development team will support quality improvement across the trust.

• Four ‘must dos’ • Promote clinical

quality

Well-established and supportive Council of Governors.

• Continue to involve Governors in the critical work streams and incidents review programme.

• Support appointed governors to develop and strengthen our relationships with local partner organisations.

• Governors keep the Board ‘grounded’ – the Board needs to support the Council in holding us to account.

• Throughout all priority work streams

Strong brand – known as a high-performing organisation.

• Use our brand-strength in our marketing work.

• Continue involvement in national groups to influence future developments – e.g. Darzi Clinical Review Group, the PbR Project Board, Foundation Trust Network.

• Provide community provider services

• Establish common care pathways across all trust services

Modern estate + low level of backlog maintenance.

• Make the most from the opportunities that come out of the Darzi Review and the APOH programme.

• Flexibility of our estate enables fully to

• Provide community provider services

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Strengths

Strength How will we harness this? Link to Work stream(s) respond to all new opportunities.

RiO. • Shift to focus of improving clinical care while maximising use of RiO.

• Improve the quality and accessibility of data through the implementation of a data warehouse.

• Continue focus on data quality.

• Part of the quality and safety improvement plan and data quality improvement plan and the development of quality report 2009/10

Responsive organisation

• We are good at identifying gaps and focusing our energies (e.g., 4 must do’s).

• Four ‘must dos’ and other quality initiatives

Weaknesses

Weakness How will we address this? Link to work stream(s) Use of data to enhance quality

• We need to review quality measures and increase focus on outcomes and the ability of managers and clinicians to use data intelligently and routinely at all levels.

This will be supported through • Our four ‘must

dos’, the Patient Experience Tracker

• Promoting Quality monitoring mechanisms within our quality dashboard and annual plan KPIs

Increase membership, particularly 14-25 age group.

• The membership committee have done events in some local schools.

• A programme to increase membership underway.

• This will be supported through work undertaken by our membership committee

Cross-directorate CREs have not been achieved.

• Cross-trust care group forums are being established to achieve CREs.

• The 2009/10 CRE programme assigns CREs to directorates and utilises bench marking work from 2009/10 to identify where efficiencies could be made across the trust

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Weaknesses

Weakness How will we address this? Link to work stream(s) Capacity of executive to pursue opportunities.

• Review directors’ capacity utilisation and expectations of the next ‘tier’ of senior management to identify how we might make better use of our senior staff resource.

• The Promoting Quality work stream will create a more quality focused governance structure ensuring capacity to promote improvements is delivered by both clinical and non clinical managers

Results of national patient survey – further progress needed in 4 areas.

• The four areas are focused around our four ‘must dos’ and will be addressed within these work streams and our quality plans

• Our four ‘must dos’ continue to be a significant focus in 2009/10

Incident and complaint management

• New requirements for complaint and incident management are to be introduced throughout the trust

• This process is linked into the Nursing and Governance plan for 2009/10

Workforce capacity and skill mix

• It is not clear if we have the capacity and capability fully to deliver requirements of SLR, NICE, etc.

• This will be reviewed as part of the HR directorate plan for 2009/10

Safeguarding Adults & Children

• This is likely to become a high government priority, given recent high profile cases.

• This work is addressed within our Social Care Leads Group and is monitored through the regular governance report to the Executive

3.7 Our priorities and plans The 2009/10 work streams and their indicators are detailed below. Individual directorates’ plans to support delivery can be found in appendix (xi). 3.7.1 Our Plans for Improving Quality Improving the quality of our services continues to be integral to our plans for 2009/10. For 2009/10, our quality objectives link to the areas of quality improvement that we believe are a priority, they are in line with nationally mandated quality requirements and have been agreed with our commissioners.

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Process for identifying our quality indicators for 2009/10 Our four ‘must dos’ – Review of these work streams supported their continuation into

our Annual Plan 2009/10

Our Quality and Safety Improvement Plan – agreed with commissioners within our

2009/10 Contract this highlights locally agreed quality standards

Improving our organisational structure to improve quality During 2008/9, we completed a quality review to ensure that we have the best structure in place to deliver high quality services and monitor quality. This included identifying Board leadership for quality in the Medical Director role and strengthening links between this role and Clinical Directors. We have also taken steps to ensure that quality is a key component of our organisational culture. Surveys show that staff are highly aware of the trust’s values and feel that they support them in their work. We have adapted our recruitment and induction processes to highlight the importance of our values. Our staff recognition awards are also structured on our values to ensure that staff are rewarded for improving the quality of the care that they provide. 3.7.1.1 Our four ‘must dos’ For each of the four ‘must dos’, the Board has agreed a set of targets for 2009/10. Must Do Target by end of 09/10 Baseline as 31st

March 2009 60% of service users on New CPA have their carer details on RiO

18.55%

50% increase in the number of carers offered or receiving a completed carer's assessment (compared with the 2008/9 baseline)

284

1. Support families and carers

25 cross trust teams to receive training in family inclusive practice

0

New website will launch for Oxleas providing up-to-date information about the organisation, services and mental illness and learning disability.

Current website

S132 compliance demonstrated through RiO recording in all cases

Current practice is manual

2. Provide information for service users

Modern matrons ensure that all newly admitted patients and their carers are offered appropriate information

Current practice in manual reporting within the Modern Matron checklist weekly returns

3. Improve care planning

All service users on New CPA have a care plan on RiO

98.56%

Our Quality Report 2008/09 – reports on our position on quality within our Annual Report. Our four priority areas are the trust four ‘must dos’ and our local indicators

linked to the three quality domains are taken from our Quality and Safety Improvement Plan.

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Must Do Target by end of 09/10 Baseline as 31st March 2009

All service users on New CPA have a crisis plan on RiO

93.51%

90% of service users on New CPA have a CPA review at least once every six months

WAA: 96.25% OA: 81.55%

All service users on New CPA are followed up within 7 days of discharge from inpatient care

100%

Delayed discharges do not breach the 7.5% target

5.69%

All appropriate staff undertake training in New CPA & risk management

N/A

CAMH & ALD services provide specialist input into the trust's new risk management guidance and training programme

N/A

Learning from complaints and PALS issues is a standard item for local governance groups and action plans are monitored effectively.

Review taking place

Reduce by 20% the proportion of complaints and PALS issues relating to staff attitude (compared with 08/09 average of all complaints).

80 (29% of total)

Ensure 95% of all complaints are resolved by the trust.

100%

4. Improve relationships with service users and carers

All acute inpatient services to use the PET and make unit-wide improvements from year-start baseline.

Currently in place in 8 of 13 WAA and OA wards

3.7.1.2 Our Quality and Safety Improvement Plan This plan is comprised of 4 nationally mandated quality standards and 10 locally agreed quality standards that link to the 3 domains of quality; safety, experience and effectiveness.

Nationally Mandated Quality Standards Standard Purpose Action Plan and Indicators Improve Care Planning for Service Users

All service users to have a care plan in line with their needs that is reviewed and updated as appropriate

• Quality reconfiguration through the ‘Promoting Clinical Quality’ work stream

• Standard best-practice caseloads for CMHTs developed and implemented

• Develop and undertake clinical quality audit of care and crisis plans

• Implement standard requirements for discharge notification to GPs

• % targets for care and crisis planning, 7 day follow up and reviews for service users on New CPA

• National Patient Survey score • Care Plan quality audit results • % delayed discharges

Reduction in mixed sex accommodation

To deliver meaningful reductions in mixed sex accommodation

• Audit existing facilities in line with requirements

• Complete feasibility study on women-only day areas

• Number of incidents relating to mixed sex accommodation

Inpatient services for 16/17 year

By 2010 no 16/17 year olds should be admitted

• Exception reporting of all cases of 16/17 year old admissions

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olds to an adult psychiatric ward (unless such an admission is in accordance with their needs)

• Development and delivery of action plan for age appropriate ward

• Number of 16/17 year olds admitted to an adult inpatient service

Healthcare associated infection (HCAI) improvement Plan

Demonstrate the lowest levels of HCAI appropriate to the care environment

• Ensure appropriate infection control procedures are in place

• Delivery of HCAI staff training and review of policy

• Number of HCAI by service Locally agreed quality improvement objectives Standard Purpose Action Plan Improving Physical Healthcare

To promote healthy life styles to service users, ensuring that physical health care needs are understood and met as appropriate

• Physical health needs to be included in best practice care plan development

• Increase access to health promotion literature in services

• Review physical health score in the National patient survey

• % care plans containing info. Of physical health

• G1-G15 medium security standards • Participation in PCT led development on

an information sharing process re. physical health needs

Improving service user and carer experience

To improve the experience of service users and carers within our services

• Provision of training in family inclusive practice

• Implementation of the carers strategy and actions through the Carer board

• Up to date information leaflets available for all services

• Modern matrons to ensure appropriate information and feedback requested on admission and discharge from services

• % carers recorded and receiving carers assessment

• Number of complaints re. staff attitude • Data from the Patient Experience Tracker

roll out • National patient survey score

Promoting Social Inclusion: Employment

To increase service users opportunities for employment (paid and unpaid), training & education and community participation

• Development of SI leads and SI work plan throughout the trust

• Creation of volunteer work placements throughout the trust

• Undertake employment audit and ensure employment status is recorded

• % service users with employment status recorded and no. in employments

• Number of service users employed or volunteering within the trust

Dual Diagnosis To produce an evidence base for development of services for dual diagnosis

• Improvement of initial screening of drug/alcohol use in core assessment

• Improve clinical coding of dual diagnosis • Improve health education and information

given to service users with dual diagnosis • Inspection and search of trust premises • % service users recorded with dual

diagnosis (compared with national

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average) Improving recording of diagnosis coding and outcome measures

To improve our understanding of service users’ needs in order to ensure best practice care packages are offered and positive outcomes

• Deliver against the trust SLR programme board project plan

• Deliver against the trust coding plan • Audit compliance with NICE guidance on

depression and schizophrenia • % diagnosis coding levels

Improving prescribing practice

To ensure compliance with best practice prescribing guidelines

• Participation in POMH national QI projects

• Continue support to clinicians in reviewing their own practice

• % achievement of standards as reported through POMH projects

Increasing access to psychological therapies

To ensure compliance with NICE guidelines for secondary mental health services

• Delivery of the trust psychological therapies action plan

• Number of service users receiving psychological therapies

• Trust wide standards set for psychology caseloads and throughput

Locally Agreed forensic specific quality improvement objectives

Standard Purpose Action Plan Specification for adult medium secure services

To achieve and maintain compliance with physical security standards to ensure national security targets are met and appropriate measures are in place to protect the privacy and dignity of patients

• Fence security project delivery by summer 2010

• MSU specialist commissioner audits undertaken and actions against recommendations

• Quarterly reporting on risks and SUIs concerning security

• Report progress against the PCT and trust agreed action plan

Promotion of throughput from forensic services

To promote and monitor the appropriate delivery of care planning to aid throughput from forensic services

• Protocol implementation for referral to and from forensic services

• Care plan review audit and discharge planning review to be undertaken

• Number of discharges per annum • Number of delayed discharges • Delivery of the forensic activity data set

Reducing substance misuse within services

To improve substance misuse awareness and reduce the number of incidents relating to substance misuse within forensic services

• Improve initial screening for drug/alcohol use in core assessment

• Improve diagnosis coding for dual diagnosis

• Regular inspections and liaison with police

• Reporting of incidents relating to illegal substances found

• No. of staff completing substance misuse training

• No. of service users attending substance misuse awareness sessions

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3.7.1.3 Our Quality Report 2008/9 The priority areas we plan to focus on, as described in our quality report are those highlighted within our 4 ‘must do’ work streams in order to ensure that our focus on quality is linked throughout our reporting mechanisms. In the second section of our quality report, we are instructed to provide an ‘overview of the quality of care offered by the trust based on performance in 2008/9 against indicators selected by the NHS foundation trust itself. The indicator set selected must include: • At least 3 indicators for patient safety • At least 3 indicators for clinical effectiveness • At least 3 indicators for patient experience’ (Monitor) In order to identify the indicators for 2008/9 we chose indicators agreed within our Quality and Safety Improvement Plan that we had already linked to the three domains of quality. 1) Patient safety measures

Rational for this measure 2007/08 2008/09 Data Source

Improve prescribing practice: % adherence to the standard for prescribing high dose anti-psychotics on adult acute wards

Prescribing medication safely and in line with best practice and NICE guidance is essential to providing a safe service. We are involved in auditing our prescribing practice through Prescribing observatory for mental health UK. Our involvement in these audits gives us a clear indication of the quality of our prescribing practice.

Prescribing appropriate dose: 73% adherence Prescribing single anti psychotic: 71% adherence Prescribing single generation anti psychotic: 80% adherence

Prescribing appropriate dose: 83% adherence Prescribing single anti psychotic: 79% adherence Prescribing single generation anti psychotic: 91% adherence

Pomh-uk & pharmacy monitoring

Reducing mixed sex accommodation: % of single sex bedrooms or bays

A National Priority for 2009/10 is to reduce the amount of mixed sex accommodation to ensure patients are cared for with privacy and dignity and in a safe environment.

100% 100% Estates Information

Meeting national standards for medium secure services: No. of 2008 national medium secure standards met in baseline inspection

New national medium secure service standards were introduced in 2008/09. A baseline assessment of our compliance with these standards which address both safety requirements for patients and the public has been undertaken. We plan to improve on this in 2009/10.

N/A 159 / 192 Medium Secure Standards Inspection

Reducing healthcare acquired

Reducing healthcare acquired infections is a key national priority for all trusts.

2 (C-Diff) 0 (MRSA)

1 (C-Diff) 0 (MRSA

National reporting

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infections: No. reporting MRSA and C. dificile cases 2) Clinical effectiveness measures


Ensuring appropriate in-patient facilities for 16/17 year olds: No. of 16/17 yr old admissions to adult psychiatric wards

In 2010/11, it will be a national standard that no 16/17 year old will be admitted to an adult psychiatric ward (unless this is in line with their needs). In 2009/10 we will be working towards this national standard against the baseline reported here.

7 8 RiO

Reducing delayed discharges: % of recorded delayed discharge occupied bed days (national requirement under 7.5%)

In 2008/09, reduction of delayed discharges became a national priority to ensure patients are cared for in the most appropriate setting and their recovery progress is not delayed.

N/A 5.7% RiO

Increasing access to psychological therapies: % of total trust caseload receiving psychological therapy

Increasing access to psychological therapies is a national priority both in primary care and secondary care services. In 2008/09, part of our annual plan was to increase availability of therapy to support recovery for our service users.

N/A 16.3% RiO

3) Patient experience measures


Staff attitude and communication: No. of times this issue was raised in complaints

Establishing good relationships with our service users and carers was one of our priority work streams in our 2008/09 Annual Plan and will continue to be in 2009/10.

73 (27%) 80 (29%) Trust complaints database

% of patients who felt they were listened to by the professional whom they last saw

Positive relationships between clinicians and service users is key to providing high quality services which meet service user needs.

84% 85% National patient survey

% of patients who felt they were involved in their care

Involvement in the care planning process can deliver better quality outcomes for service users as this


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planning encourages engagement in the plan and ensures the plan picks up all care needs.

% of patients who received sufficient information about medication

Providing service users with good quality information about their care, especially medication, supports compliance with medical prescribing.


% of patients who felt carers were supported

Carers’ involvement in service users’ care can be vital. Therefore supporting carers can have a significant impact on the overall quality of the care we provide to service users.


In 2009/10 we plan to improve the availability of good quality metrics to help us report on the quality of our services. This may require us to change and further develop some of the current metrics reported above in order to ensure we accurately capture and report on our plans for quality improvement and those areas of quality care which our stakeholders inform us are of most importance. In order to ensure we have patient reported outcome measures (PROMS) and carer reported outcome measures (CROMS) to compliment our own reportable indicators on quality we will be rolling out the use of the Dr Foster Patient Experience Tracker (PET) to all adult in-patient wards, functional older adult inpatient wards as well as providing a PET unit in each acute inpatient location specifically requesting feedback from carers. In our 2009/10, this feedback will be provided to support our quality report. 3.7.1.4 Our Data Quality Improvement Plan In our 2009/10 contract, we agreed the improvements to data quality in order to support future monitoring of quality objectives, details can be found in appendix iv. 3.8 Our five trust wide Priority Work streams 3.8.1 Promoting Clinical Quality In order to support the work being undertaken in section 3.6 we plan to enhance clinical quality through improved leadership and management of clinical quality processes. This will provide us with the internal structure required to lead our quality objectives in 2009/10 and the appropriate mechanisms for monitoring progress. Priority Work stream Target by end of 2009/10

Review the trust’s clinical quality structures Implement the 2009/10 quality improvement plan agreed with our PCTs Produce approved quality report at the end of 2009/10 Produce a ‘quality dashboard’ for the board by the end of 2009/10 Achieve NHS Litigation Authority level 2

1 Promote Clinical Quality

Increase by 50% the number of incidents reported at levels 1-3 (2008/09 baseline 1,984)

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3.8.2 Integrating community provider health services In 2008/9, Bexley Care Trust chose us as their preferred provider of Bexley community health services. There are 31 different health services provided by the PCT Provider unit with a total 486 staff and a budget of approximately £25million. We feel that we are in an excellent position to be the provider of these services for the following reasons: • We have previously provided community health services • Providing community health services would support us in delivering a more

holistic method of care to both community and mental health service users in Bexley

• Opportunities to support out of hospital options for people and promote independence and social inclusion

• We have the organisational culture, governance structure and financial stability to support successful delivery of these services

Priority Work stream Target by end of 2009/10

Successful integration of Bexley community services (based on the outcome of due diligence)

2 Provide Community Provider Services

Submit bids to Bromley and Lewisham PCTs An integration Project Board has been set up, a project manager has been appointed and the trust has engaged Price Waterhouse Coopers to support the project. We are currently undertaking a due diligence process regarding transfer of Bexley services. Following due diligence there will be a business analysis process leading to a business case that will be presented to the Board of Directors. As the financial implications are not presently known, we have not included any financial data in this annual plan. Part of the business case will be to show the effect on our financial position and therefore a revised annual plan will be produced for discussion when the financial information is known. The transfer will take place after successful conclusion of these rigorous processes and will be post December 2009. The trust is also in discussions with Bromley and Lewisham PCTs regarding their community services. We are on a shortlist of two in Bromley; a board paper is being development to go to Bromley PCT Board in June. A PQQ was submitted to Lewisham PCT in April 2009 and we have also been short listed down to a choice of two providers for Lewisham services. The trust will apply the agreed Board criteria for new business development before a decision is taken as to whether or not it moves into Lewisham or Bromley. 3.8.3 Establish common care pathways across all trust services In order to link clinical quality, service outcomes and finance in a standardised way across trust services we will continue to be involved in the pan London SLR and PbR projects in 2009/10. This will enable us to support agreement and development of the following set of 'currency products': • A summary needs assessment tool; • A complete set of needs-based profiles • A set of standard care packages for each of the identified needs profiles with

specific aims, interventions, activities and outcomes; • A robust, reliable and replicable methodology for allocation to needs profiles /

care packages

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• A care package review methodology; • A care package costing methodology. A trust programme board has been established to lead this work supported by significant clinical engagement. Priority Work stream Target by end of 2009/10

Implement the national care pathways and packages work and meet the trust’s service line reporting (SLR) Project Board plan milestones

3 Establish common care pathways across all trust services

Implement New CPA as per the National Institute of Mental health’s self assessment tool

3.8.4 Promoting social inclusion: improving access to employment and

meaningful day opportunities This work will be led by a newly appointed trust head of social inclusion and directorate leads for social inclusion through the social inclusion steering group. The focus in 2009/10 will be on employment. Priority Work stream Target by end of 2009/10

Increase to 70% the proportion of adult service users with their employment or training status recorded on RiO (08/09 baseline 57%) Increase by 10% (to 1,367) the number of service users who are supported into employment or training (08/09 baseline 1,243 service users in employment)

4 Promote Social Inclusion

Increase by 20, the number of service users undertaking voluntary or paid employment within the trust (compared with the 2008/9 baseline of 61)

3.8.5 Increasing our capacity to provide psychological therapies This work is being led by the Director for Psychological Therapies through the Psychological Therapy Board. In addition, the Greenwich Directorate will be managing the implementation of primary care IAPT services in 2009/10. Priority Work stream Target by end of 2009/10

Increase by 10% the number of service users receiving psychological therapies (08/09 baseline 16.3%)

5 Increase access to psychological therapies

Put in place trust wide standards for caseloads and expected throughput for the different psychological therapies

3.8.6 Summary of other directorate priorities and plans Alongside the trust wide annual plan priorities, each directorate has developed local plans for 2009/10. The following sections on service developments and investments highlights the main plans for 2009/10 requiring financial support. A more detailed overview of these plans can be found in appendix xi.

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3.9 The financial and investment implications of our plans The table below shows the main outcomes of our strategy and plans: Actual

08/09Plan

09/10Forecast

10/11 Forecast

11/12EBITDA Margin 7.1% 5.1% 5.0% 5.0%Surplus / (deficit) (£m) (£0.37m) £2.03m £2.01m £2.14mSurplus before exceptionals (£m) £4.1m £2.03m £2.01m £2.14mLiquidity (days) 99 91 96 99Risk rating 4.5 3.7 3.7 3.7CRE (Efficiency savings) £1.1m £2.5m £3.6m £3.7mCapital Expenditure £1.8m £3.46m £3.12m £2.78mNet Borrowing Nil Nil Nil Nil

The sections below give a description and detail of how we developed our financial plans and forecasts. 3.9.1 Service Investments Below are detailed the main outcomes of our strategy and service development plans for the years 2009 through to 2011/12 (taken from the above trust wide work streams plus any directorate specific plans in appendix xi). Section of

Annual PlanCapital

£’000 Revenue

£’000Commissioned developments Greenwich home treatment team expansion Greenwich

Directorate 225

Delivery of a 16/17 year old age appropriate inpatient ward

Nursing and Governance

80

Management of Greenwich IAPT Greenwich Directorate

200 1000

Internally funded developments Increasing access to psychological therapies

Priority Workstream

250

Promoting social inclusion Priority Workstream

20

Supporting families and carers Must Do Priority Workstream

135

Review of compliance with the Hygiene Code

Nursing and Governance

260

Implementation of the ligature policy Nursing and Governance and

Estates and Facilities

200

Integration of Community Unit from Bexley Priority Workstream

300

Assuring compliance with the Hygiene Code Estates plan 260Menu Improvement for inpatient acute wards

Estates plan 100

Environment improvements Estates plan 800Improving relationships with carers – implementation of carers strategy

Priority workstream

70

Promoting Clinical Quality – implementation of new quality structure

Priority Workstream

100

Information system Directorate plan 100

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Further details of the above service developments which are part of individual directorate annual plans for 2009/10 can be found in the annual plans summary in appendix xi. The trust is in the process of undertaking the due diligence relating to the proposed amalgamation of the Bexley Community Provider Unit. Once this is complete we will be preparing the business case. As this is a significant increase in the service and turnover of the trust there will be a revision of this Annual Plan prepared when the full information is available, has been processed, and the risks determined and assessed. The revenue cost noted above relates to the estimated cost of undertaking the due diligence and developing the business case. Capital plans to support our priority work streams and directorate plans are detailed below and in appendix vii. 3.8.2 Cash releasing efficiency (CRE) savings programme Our overall financial plan and forecasts also take account of our efficiency plans. In addition to our four ‘must dos’ and five priority work streams we will continue our financial efficiency programme. In 2009/10 our plans for the trust are to achieve an efficiency of 2.5% spend in year. This target will also roll forward in to the following two years although may be adjusted as required based on our financial position. Each service directorate has been apportioned a part of the overall saving required based upon benchmarking work undertaken in 2008/9. The trust targets for efficiency plans are: Year £.m2008/09 Actual £1.122008/09 Plan £1.832009/10 Plan £2.502010/11 Plan £3.602011/12 Plan £3.70 During 2008/09 the directorate plans were achieved, but the cross trust plans were not fully achieved due to changes in service demand affecting the original plans. The requirements for the plan period require an increase in savings and we have prepared full savings programmes for 2009/10, and partial ones for future years. All plans are for recurrent savings. We have a range of non-recurrent plans which can be implemented if the need arises. The summary of the plans is shown in appendix vi. 3.10 Financial Forecast Summary 3.10.1 Financial Planning Process The overwhelming majority of our income is from block contracts with Bexley, Greenwich and Bromley PCT’s with smaller Block Contracts and Section 75 pooled budget agreements with Lewisham PCT, and the boroughs of Bromley and Greenwich.

The plans are drawn up to reflect any changes in these contracts. These changes are normally as a result of proposals put forward by the trust. All the changes are

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subject of business cases and are reviewed at the appropriate level of management. Each directorate develops its annual plan to take account of the purpose, values, strategic objectives and organisational ‘must dos’. These are supported by the Board. The resultant directorate business plans are agreed by the Chief Executive and reviewed at regular intervals through the year. The service directorate plans also reflect local priorities. 3.10.2 IFRS The impact is very marginal on both Balance Sheet and I&E Account. There has been the capitalization of a lease. This adds £400,000 to Fixed Assets. The effect on the I&E account is less than £20,000. 3.10.2 Phasing Most income is block and is evenly spread over the year. For developments there is phasing for when both income and expenditure arise during the year. This is a very small part of both income and expenditure. 3.11 Investment and disposal strategy 3.11.1 Capital expenditure As noted in the 2008/09 plan, the large redevelopment of Memorial and Goldie Leigh Hospitals completes the trust’s major investment programme. For the foreseeable future expenditure will support the changes in models of care and efficiency in use of our estate. There are a number of DoH requirements that need capital investment – most notably the security requirements at the Medium Secure Unit. There are no major capital projects planned. However, the emerging plans arising from national and local strategies are beginning to become apparent. The move towards the integration of community provider units within the trust is one of these changes. At present we are not far enough into this process to identify significant capital expenditure requirements, but our cash and borrowing limits put us in a strong position to take these and other opportunities for the future. 3.11.2 Capital Projects The following are the major projects for 2009/10: • Internal refurbishment of Memorial (Cost £1m): This is the final phase of the

redevelopment of Memorial Hospital. • Goldie Leigh Hospital (Cost £0.25m): Completion of the major project. • Greenwich IAPT (Cost £0.2m): This is an allocation for work to be undertaken

when the contract for IAPT is awarded. • Bracton Step Down (Cost £0.6m): There is a need to provide new and enlarged

accommodation for the pre-discharge unit at the Medium Secure Unit. This is related to quality of care and facilitating the throughput of patients.

• Ivy Willis House (Cost £0.3m): The plan is to move a care unit to more suitable accommodation. The costs relates to upgrading the internal accommodation of an existing building.

• Shepherdleas Ward (Cost £0.2m): The older people’s accommodation at Memorial needs to be altered to allow for less beds and more community related facilities.

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Further details of the full Capital Expenditure Plan for 2009/10 can be found in appendix vii. Protected Assets

The only protected asset that may be affected in the next year is Philipott Path. This is on the same site as a larger Greenwich TPCT facility. The PCT wants to purchase Philipott Path from the trust and develop the whole site. 3.12 Finance and working capital strategy The trust has a Working Capital Facility of £10m. The agreement lasts until March 2010. The facility, that is for a committed funding was not used in 2008/09 and is not planned to be used in 2009/10. 3.12.1 Borrowings We are not planning to borrow further funds within the plan period. 3.12.2 Prudential Borrowing Code For the period there are no plans that would alter the PBL. 3.11.3 Liquidity The trust has a high level of liquidity which is well in excess of the Monitor requirement for a financial rating of 5 (60 days). The plan is to maintain this high level. 3.13 Summary of Key Assumptions 3.13.1 The effect of the national economic position. The contracts for 2009/10 are agreed and reflect the NHS funding changes. In future years the increase in efficiency requirements that were part of the National Budget detail, have been included. For 2011/12 we have not incorporated any more income reduction, but the trust has drawn up some outline mitigation plans that will be further developed over the next two years.

3.13.2 Effect of the Local Health Economy The local health economy remains in a financially uncertain position. Significant changes in the acute health provision covering our three local PCT areas have been approved by the Secretary of State, leading to a single acute provider across the three boroughs (amalgamating three former trusts). Given the size of the financial problems within the new acute trust, we are assuming that there will be no growth for mental health and learning disability services beyond the agreements reported in section 3.13.3. For 2009/10 extra beds have been commissioned by local PCT’s in our Medium Secure Unit and the intensive care unit. All of these have been funded from the out of area income in order to bring the service users into local services. The Local

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Authorities are already affected by the national economic downturn and their income is reducing. There is therefore no growth in funding from them.

3.13.3 Income As noted above, there has been some movement of funding from out of area placement (High Cost Low Volume) to the block contracts. This has no effect on our overall income. It does reduce the risk of not being able to fill our uncommissioned beds by spot selling to other PCT’s and trusts. (This applies to the Medium Secure unit and the Intensive Care Unit). There has been some technical changes in the source of income. Both in Bexley and Greenwich some income that previously come from local authorities has now been added to PCT income. There is new income arising from the outturn in 2008/09. For out of area placements we have a risk share arrangement in each current year, and the outturn is fully funded in subsequent year. The increase in 2009/10 is £0.9m. There is a small increase in income arising from the full year effect of previous year’s developments, this is £0.5m. Developments in Assertive Outreach Teams and extra beds in the Medium Secure Unit are funded by transferring income from Out of Area Income to the Block Contract. This has no effect on total income. The commissioners of the Medium Secure Unit services have agreed to consolidate some variable costs into the overall unit price. This increases the block income and reduces the variable income. (This covers such items as exceptional observation costs). 3.13.4 Income Inflation All NHS income has been uplifted by 1.7% and Local Authority by 2%. For future years the NHS is reduced to 1.2%.

3.13.5 Expenditure For the funded developments the income and expenditure are equated. There are a number of internal developments related to the trust objectives and a total of £1.4m has been included for these changes. The trust has an Opportunity Fund which accessed by bids from Directorates. These are for projects that contribute to our objectives that will help fund future savings, cover transitional costs, pump prime self sustaining developments etc. This will be a total of £0.5m. The extra income arising from outturn is covered by an equal expenditure. The revaluation in 2007/08 resulted in a large reduction in asset values. This has a full effect in 2009/10 in reducing PDR dividend and depreciation.

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3.13.6 Expenditure Inflation Pay and non-pay inflation is 3% for 2009/10 and this is reduced for pay to 2.5% for 2010/11 onwards. Drug increases are planned at 10%. 3.13.7 Summary Income & Expenditure 2008/09

Actual£.m

2009/10Plan£.m

2010/11 Plan £.m

2011/12Plan £.m

Mandatory clinical income 120.6 125.6 127.1 128.6Non Mandatory clinical income 6.1 4.8 5.1 5.1

Other 6.9 5.0 4.9 5.0Total income 133.6 135.4 137.0 138.7

Pay (88.5) (92.7) (93.9) (94.6)Drugs (2.5) (2.6) (2.7) (2.9)

Clinical supplies (0.2) (0.1) (0.1) (0.1)Secondary Commissioning (12.5) (10.3) (10.5) (10.8)

Other (20.3) (22.8) (22.9) (23.2)Total costs (124.0) (128.5) (130.1) (131.7)

EBITDA 9.6 6.9 6.9 7.0Profit on disposal of assets 0.0

Impairments (4.5) Depreciation (2.2) (2.2) (2.2) (2.2)

Interest receivable 1.4 0.5 0.5 0.5Interest payable (0.6) (0.6) (0.6) (0.6)

PDC Dividend (4.1) (2.5) (2.5) (2.5)Retained Surplus / Deficit (0.4) 2.0 2.0 2.1

3.13.8 Summary Balance Sheet 2008/09

Actual£.m

2009/10Plan£.m

2010/11 Plan £.m

2011/12Plan £.m

Fixed assets 98.7 100.3 101.2 101.8Stock 0.1 0.1 0.1 0.1Debtors 3.2 6.2 6.2 6.2Cash / Investments 40.3 36.4 38.9 41.2Current assets 43.6 42.7 45.2 47.5Creditors (12.4) (10.7) (11.1) (11.8)Accruals (6.2) (6.2) (6.2) (6.2)Deferred income (.8) (0.8) (0.8) (0.8)Current liabilities (19.4) (17.7) (18.1) (18.8)Longer term creditors / provision (11.4) (11.4) (11.5) (11.5)Total assets employed 111.4 113.9 116.8 119.0 Public Dividend Capital 67.3 67.3 67.3 67.3Income & Expenditure Reserve 2.6 4.6 6.5 8.7Revaluation Reserve 40.3 40.8 40.8 40.8Other 1.2 1.2 1.2 1.2Charitable Funds 1.0 1.0Total funds employed 111.4 113.9 116.8 119.0

Note: From 2010/11 onwards the trust’s charitable funds are consolidated into our Balance Sheet.

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3.13.9 Summary Cash Flow 2008/09

Actual£.m

2009/10Plan£.m

2010/11 Plan £.m

2011/12Plan £.m

EBITDA 9.6 6.9 6.9 7.0Movement in:-

Debtors (0.6) (3.0) Creditors (1.0) (1.7) 0.3 0.8

Deferred income 0.5 Provisions 0.9

Other changes in working capital 1.0 Cash flow from operations 9.2 2.1 8.2 7.7

Capital spend (1.9) (3.5) (3.1) (2.8)Interest paid (0.6) (0.6) (0.6) (0.6)

Interest received 1.5 0.5 0.5 0.5Repayment of loans (0.2)

Dividends (4.2) (2.5) (2.5) (2.5)Net cash inflow / (outflow) 4.0 (3.9) 2.5 2.3

Closing Cash Balance 40.3 36.4 38.9 41.2

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4. Risk Analysis 4.1 Governance risk 4.1.1 Governance commentary Legality of Constitution At the Annual Members Meeting on 24 September 2008, two changes to the constitution were proposed. These changes were recommended as the existing wording was felt to be too constrained. The revised wording will enable the trust more successfully to appoint governors who can contribute to the social inclusion work stream. Paragraph 12.5.2 Existing wording: The Bromley Chamber of Commerce, working with Greenwich, Bexley and Lewisham Chamber of Commerce to appoint one partnership governor. Replace with wording: One partnership governor to be appointed from the business community Paragraph 12.5.7 Existing wording: Job Centre Plus, to appoint one partnership governor. Replace with wording: A representative from an organisation supporting the social inclusion of people with mental illness or learning disability to be appointed as a partnership governor. The Annual Members Meeting unanimously agreed these changes. Growing a representative membership In April 2008, the trust had a membership of 4169. To date, we have a membership of 4593, made up of 2267 staff members, 1536 public and 790 service user / carer members. This represents an increase of 10% and 424 more than in April 2008. The largest percentage increase (15%) is within the public constituency. Board roles, structure and capacity The Board maintains its register of interests, and can confirm that there are no material conflicts of interest for Board members. The Board is satisfied that all directors are appropriately qualified to discharge their functions effectively, including setting strategy, monitoring and managing performance and ensuring sufficient management capacity and capability. The selection process and training programmes in place ensure that the non-executive directors have appropriate experience and skills. The management team has the capability and experience necessary to deliver the annual plan.

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The management structure in place is adequate to deliver the annual plan objectives over the next three years. Clinical quality The Board is satisfied that, to the best of its knowledge and using its own processes Oxleas NHS Foundation Trust has and will keep in place effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients. Service performance The trust has met all its performance targets required by both the Healthcare Commission and Monitor. Details of these targets and our performance against them can be found in section 2. The Board is confident that the trust has the capacity to meet the required service targets for 09/10. Risk management Issues and concerns raised by external audit and external assessment groups (including reports for NHS Litigation Authority assessments) have been addressed and resolved. Where any issues or concerns are outstanding, the Board is confident that there are appropriate action plans in place to address the issues in a timely manner. The trust achieved Clinical Negligence Scheme for trusts accreditation at Level 2 in January 2007 and will be assessed against Level 2 of the NHS Litigation Authority Risk Management Standards for mental health and learning disability trusts in November 2009. All recommendations to the board from the audit committee are implemented in a timely and robust manner and to the satisfaction of the body concerned. The necessary planning, performance management and risk management processes are in place to deliver the annual plan. A Statement of Internal Control (SIC) is in place, and the NHS foundation trust is compliant with the risk management and assurance framework requirements that support the SIC pursuant to most up to date guidance from HM Treasury (www.hm-treasury.gov.uk). All key risks to compliance with the trust’s authorisation have been identified and addressed. Co-operation with NHS bodies and local authorities The trust has positive contracting and planning relationships with the PCTs of its three host boroughs and with the commissioners of forensic services at Lewisham PCT. Good working relationships have also been developed with the Overview and Scrutiny Committees of Bexley, Bromley and Greenwich local authorities. The trust has Section 31 partnership agreements in place with the local authorities of each of its three constituent boroughs for the integrated provision of health and social care in working age adult mental health services. These arrangements have

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encouraged a welcome focus on mental health from local authority commissioners to the benefit of all local stakeholders. The structure of the Section 31 agreement differs in each of the three boroughs:

• Bexley Care Trust is the local commissioner of health and social care and has a commissioning Section 31 agreement, established in 2002. Trust services are commissioned from a pooled budget of health and local authority resources for working age adult mental health services.

• In Bromley, the Section 31 agreement is a provider agreement and in 2004, it established the trust as the lead provider of mental health care for adults of working age.

• In Greenwich, there is also a provider Section 31 agreement, established in 2003.

Greenwich also has a commissioning Section 31 in place for adult learning disability services. This is between Greenwich Teaching PCT and the London Borough of Greenwich and was signed in October 2006. Under this new arrangement, LB Greenwich has become the lead commissioner of ALD services for the borough. The Section 31 agreements have served to change the culture within the trust – many managers now have social care backgrounds (including one of our directors) and this has heightened the profile of social care and progressed social inclusion work. The forensic and prison services directorate has an established track record of partnership working with a number of agencies. Within the criminal justice arena, the service works with four Magistrates’ Courts across its geographical patch, providing locally based court-diversion services. Links have also been developed with partners in probation and social services to provide an assessment and treatment programme for sex offenders and the service provides support to three local probation hostels as part of the resettlement support for men released from prison. The directorate works closely with the police and is represented on all of the local multi agency public protection panels (MAPPAs). Although not operating under formal partnership arrangements, child and adolescent mental health services are delivered within a multi-agency context and Oxleas is an active member of each of its constituent borough’s Children’s trusts. 4.1.2 Significant risks The board has identified that provision of Bexley Community Provider services could pose a risk to governance if the quality of services do not meet current standards. Our mitigation plan against this possible risk is our commitment to undertake a full and robust due diligence process. A final decision will be made by the board based on the due diligence and subsequent business case. We will also ensure we provide the required information to Monitor concerning this service as this becomes available. Transfer will require satisfactory completion of these processes and will be post December. The Board predicts that we will remain at all times compliant with the seven elements of governance as defined in the Compliance Framework.

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4.2 Mandatory services risk 4.2.1 Mandatory services commentary We will continue to provide our contracted mandatory services as detailed in Schedule 2 during 2009/10. The following changes to our 08/09 mandatory services schedule should be noted: Changes within the 2009/10 Contracts: • Older adults’ services in Greenwich: Shepherdleas older adult ward provides

inpatient care for patients with both functional and organic disorders. Service improvement work in 2008/09 delivered a reduction in bed occupancy. The ward has reduced in capacity to 21 beds from 1st January 2009 and funding has been moved to the community teams to provide greater support for older people to receive the care they require at home. This change is reflected in the bed numbers in schedule 1 and 2. In 2010/11, we plan further to reduce the ward to 18 beds and strengthen the provision of community home treatment services.

• Older adults’ services in Bromley: In 2008/09, the Bromley directorate made

improvements to the delivery of older adult community services through amalgamating the three existing teams into two. The service provided continues to meet the needs of the same population.

• Contracted forensic services: Although external placements have decreased

they have not decreased as much as hoped due to requirements for forensic and challenging behaviour beds growing alongside the need to support prison transfers into our services within a two week time period. With this in mind, our commissioners have contracted increased numbers of forensic beds within 2009/10. Greenwich (3 extra beds), Bexley (2 extra beds) and Bromley have clarified their commissioning arrangements for rehab and forensic beds. Lewisham PCT has reduced their number of contracted forensic beds by two.

• Contracted PICU beds for Bexley: The requirement for PICU services within

Bexley has increased in 2008/09 and led to significant spend on un-contracted PICU service provision. Bexley PCT have therefore commissioned an extra bed within Oxleas’ PICU to provide for this growth in demand.

• Income generation within Learning Disability services: In support of plans

for cost efficiencies, in 2009/10, we plan to generate income through providing an extra capacity of one bed within the inpatient learning disability service.

None of the above changes pose a risk to the provision of mandatory services. It should also be noted that schedule 1 includes the provision of beds not detailed in the contracted service specifications in schedule 2. The reason for this is our provision of extra capacity to provide a service when demand fluctuates. 4.2.2 Significant risks In 2009/10 we will be undertaking a review of our inpatient services provision for both working age and older adults in order to ensure the most efficient use of this

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resource. This review may lead to changes in the provision of our inpatient wards in future. We are involving our commissioners in this process of review to mitigate against any risks to our reputation and finances. 4.3 Financial risk 4.3.1 Financial commentary The planned financial risk ratings are:

2008/09 2009/10 2010/11 2011/12 Actual Rating Plan Rating Plan Rating Plan Rating EBITDA Margin 7.1% 3 5.1% 3 5.0% 3 5.0% 3 EBITDA Achieved

117.9% 5 - 5 - 5 - 5

ROA 7.4% 5 4.0% 3 3.9% 3 3.9% 3 I&E Surplus 3.0% 5 1.5% 3 1.5% 3 1.5% 3 Liquidity 99.3 5 91 5 96 5 99 5 Weighted average

- 4.5 - 3.7 - 3.7 - 3.7

The trust is planning for a lower financial risk rating than the outturn for 2008/09. It is trust policy to have I&E Reserves and liquidity that provides strength and stability. Once the target levels are achieved the trust will invest all surpluses into service improvement. At present, the I&E Reserve is not at a level that demonstrates adequate strength and stability. However, the liquidity is above what is required.

The trust does not intend to build the I&E Reserves over a short period, and feels that over the next 2-3 years there is sufficient stability to be able to invest in services while building the reserves at a moderate rate.

During 2009/10, the trust will invest approximately £2.5m revenue in quality and other improvements. This amount is over and above mandatory requirements. The major areas of spend are shown in the table of key service developments.

The trust is planning to maintain the FRR in the range of 3.3 to 3.9. This will enable us to build the I&E Reserve over a period of 2 to 3 years while still investing in quality and services. 4.3.2 Significant risks The table below sets out the risks identified, their potential impact and our mitigation strategies.

Risk Potential

Impact Likelihood Mitigation Residual

Risk Non achievement of efficiency savings

The financial effect would be in the range of £500k - £1m

The trust has a good record of achieving recurrent savings, however the areas of savings are diminishing. In addition, there are risks of slippage.

There are a range of non recurrent savings that could be made if needed. The plan includes a contingency of £0.8m

£200k

Demand Historically this In recent years the main There has been further £500k

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Risk Potential Impact

Likelihood Mitigation Residual Risk

pressure resulting in over spend on private placements

can be up to £1m

pressure has been on the specialist services

investment in community services as a way of reducing the pressure. PCT’s have commissioned more specialist places. The trust and PCTs have a risk share agreement in place.

The Personality Disorder Centre. The centre has income to cover two more years. At the end of this time there will be a need to secure longer term income from local PCT’s.

Annual cost is £500k

The indications are that the service is clinically and financially effective. There are national policies to increase personality disorder services.

The service could be closed and alterative use found for the building.

£100k until an alternative use is found for the building.

New Mental Health Contract and Payment by Result

£2m The new contract has been postponed for a year. There are risks of financial reductions for failing to provide quality services. PbR is due at the end of the 3 years planning period. The trust is at risk if: • Costs are high • Activity is not

achieved • Activity is not

recorded

The trust has a good quality record and is continuing to invest further. The trust is well prepared for PbR and will be investing in further systems to record and monitor activity.

£1m

Loss of income through competition.

£500k The trust has a number of contracts for clinical and non-clinical services that could be removed at short notice and/or subject to competitive tender.

The services provided are of high quality so we are in a good position to retain them. We are also in a strong position to gain new contracts to either replace or increase our income.

£100k

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The impacts of these risks on the Financial Risk ratings are: Risk Mitigated Financial

Risk Risk Rating

Non-achievement of CRE £200k 3.3 Private Placements £500k 3.0 Personality disorder centre £100k 3.3 Mental Health Contract / PbR £1m 3.0 Loss of non mandatory income £100k 3.3

4.4 Risk summary The Board has considered all likely future risks to compliance with the terms of our authorisation going forward; the level of severity and likelihood of a breach occurring and the plans for mitigation of identified risks. The Board has considered appropriate evidence to review these risks and has put in place action plans to address them where required to ensure continued compliance with the terms of our authorisation. No significant risks to the stability of the trust have been identified.

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5. Declarations and Self-Certification (Monitor template declaration attached) Clinical Quality The board of directors confirms the following: • The board is satisfied that, to the best of its knowledge and using its own

processes (supported by Care Quality Commission information and including any further metrics it chooses to adopt), its NHS foundation trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients; and

• The board will self certify annually that, to the best of its knowledge and using its

own processes, it is satisfied that plans in place are sufficient to ensure ongoing compliance with the Care Quality Commission’s registration requirements.

Service Performance The board of directors confirms the following: • The board is satisfied that plans in place are sufficient to ensure ongoing

compliance with all existing targets (after the application of thresholds) and national core standards, and a commitment to comply with all known targets going forwards.

Risk Management The board of directors confirms the following: • Issues and concerns raised by external audit and external assessment groups

(including reports for NHS Litigation Authority assessments) have been addressed and resolved. Where any issues or concerns are outstanding, the board is confident that there are appropriate action plans in place to address the issues in a timely manner;

• All recommendations to the board from the audit committee are implemented in a

timely and robust manner and to the satisfaction of the body concerned; • The necessary planning, performance management and risk management

processes are in place to deliver the annual plan; • A Statement of Internal Control (“SIC”) is in place, and the NHS foundation trust

is compliant with the risk management assurance framework requirements that support the SIC pursuant to the most up to date guidance from HM Treasury (see http://www.hm-treasurey.gov.uk);

• The trust has achieved a minimum of Level 2 performance against the

requirements of their Information Governance Statement of Compliance (IGSoC) in the Department of Health’s Information Governance Toolkit; and

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• All key risks to compliance with their Authorisation have been identified and addressed.

Compliance with the Terms of Authorisation The board of directors confirms the following: • The board will ensure that the NHS foundation trust remains at all times

compliant with their Authorisation and relevant legislation; • The board has considered all likely future risks to compliance with their

Authorisation, the level of severity and likelihood of a breach occurring and the plans for mitigation of these risks; and

• The board has considered appropriate evidence to review these risks and has put

in place action plans to address them where required to ensure continued compliance with their Authorisation.

Board roles, structure and capacity The board of directors confirms the following: • The board maintains its register of interests, and can specifically confirm that

there are no material conflicts of interest in the board; • The board is satisfied that all directors are appropriately qualified to discharge

their functions effectively, including setting strategy, monitoring and managing performance, and ensuring management capacity and capability;

• The selection process and training programmes in place ensure that the non-

executive directors have appropriate experience and skills; • The management team have the capability and experience necessary to deliver

the annual plan; and • The management structure in place is adequate to deliver the annual plan

objectives for the next three years. Signature Signature

Stephen Firn Dave Mellish In capacity as Chief Executive & In capacity as Chairman Accounting Officer Signed on behalf of the board of directors, and having regard to the views of the governors.

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6. Membership 6.1 Trust constituencies The composition of the trust’s constituencies is as follows:

• A service users / carers constituency (twelve seats) - this is open to people over 14 years of age, who are current service users or carers, or who have been service users or carers within the five years preceding the date of their application.

• A public constituency (four seats in Bromley, four in Bexley and four in Greenwich) – this is open to people over 14 years of age who are resident in the London Boroughs of Bexley, Bromley or Greenwich.

• A staff constituency (one seat in each staff group: working age adults, older adults, children and adolescents, learning disabilities and corporate and partner services) – this constituency is open to individuals who are employed by the trust. Staff working in services contracted by Oxleas are also eligible to join this constituency.

6.2 Membership report The tables below provide details of:

• Changes to our membership during the past twelve months and planned growth during 2009/010;

• The demographic composition of our membership.

Public Constituency Staff Constituency Patient Constituency Membership size and movement

Last Year (actual)

Next Year (estimate)

Last Year (actual)


Last Year (actual)


At year start (1st April) 1331 2059 779

New Members 223 251 27

Members Leaving 18 43 16

At year end (31st March) 1536 1612 2267 2753 790 830

Additional Staff Constituency On completion of the due diligence process, it is anticipated that Oxleas will take on Bexley community provider services in early 2010. These services are delivered by 486 staff who would become members of the trust at the point at which these services are transferred.

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Public Constituency – Age Analysis

Age Number of Members Eligible Membership

14 – 16 31 160,781

17 – 21 113 47,194

22+ 1388 545,546

Age not known for 4 public members

Public Constituency – Gender Analysis


Male 644 364,764

Female 879 388,757

Gender not stated for 13 public members

Public Constituency – Ethnicity Analysis

Ethnicity Number of Members Eligible Membership

White 1182 635,524

Mixed 27 14,130

Asian or Asian British 61 29,517

Black or Black British 181 38,655

Other 28 35,695

Ethnicity not stated for 57 public members

Public Constituency – Socio-Economic Analysis

Socio-Economic Group Number of Members Eligible Membership

ABC1 885.26 289,731

C2 266.28 70,228

D 314.88 74,728

E 118.58 27,972

Note regarding socio-economic data:

The NRS system uses 2001 census data whereas ACORN uses 2008 population figures. The significant growth in the population of these areas between 2001 and 2008 would explain part of the difference between the eligible membership totals. ACORN uses total population figures, whereas NRS data is only available for employed individuals aged between 16 and 64.

Patient Constituency – Age Analysis


0 – 16 2

17 – 21 26

22+ 748

17,396

Age not stated for 14 patient/service user members

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6.3 Membership commentary During 2008/09, the trust focused on increasing membership amongst young people (14 to 25 year olds). In July 2008, the trust launched a dedicated CAMHS website. An event was held at Danson Youth Centre, which was attended by various staff, members of the Bexley Youth Council and other youth projects. As an incentive to join the membership, Oxleas arranged for a branded wrist band, holding a 1 GB memory stick to be given to anyone aged between 14 and 25 who completed a membership form. In October 2008, Oxleas visited the Priory School in Orpington to raise awareness of mental health and membership in a bid to reach out to our youth population. Following the initial visit, the trust, the school and the news agency, Headliners, collaborated to produce a mental health themed magazine for young people. Ten young pupils from the school's sixth form will be trained by professional journalists in the skills to plan, research, write, edit and design the magazine. At the start of the year, there were 97 young people in the public constituency and 44 in the service user/carer constituency. At year end, these figures had increased to 208 and 51 respectively, an overall increase of 84%. Increase in membership in the 14 – 25 year old age group

March 2008 New members March 2009 % change

Public (14 – 25) 97 111 208 + 114%

Service user (14 – 25) 44 7 51 + 16%

Total (14 – 25) 141 118 259 + 84%

6.3.1 Changes to the membership

May 2006 March 2007 March 2008 March 2009 % change

Staff* 1904 1897 2059 2267 + 10%

Public 1164 1271 1331 1536 + 15%

Service user 742 783 779 790 + 1%

Total 3810 3951 4169 4593 + 10%

* The staff membership is dependent upon staffing establishments and vacancy rates. 6.3.2 The work of the trust’s Membership Committee Election 2008 All elections to the Board of Governors are held in accordance with the election rules, as stated in the constitution. There have been no changes to electoral ward boundaries and the trust continues to commission the Electoral Reform Society to run its elections according to the regulations set out in the constitution.

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Turnout In 2008, 12 seats became vacant as follows: • Public Bexley: 1 to elect • Public Bromley: 1 to elect • Public Greenwich: 2 to elect • Service user/carer: 5 to elect • Staff: 4 to elect Election turnout for the three public seats and the five service user/carer seats is summarised in the table below. Only one nomination was received for the public Bexley seat and the candidate was elected uncontested. Only one of the staff group vacancies received a nomination. This was the corporate and partner organisation group and the candidate was elected uncontested. A by-election was held for the two vacancies in older persons and learning disabilities. Both these seats were elected uncontested. The working age adult seat became vacant in September 2008 and this vacancy was included in the by-election.

Public: Bromley (1 to elect)

Public: Greenwich (2 to elect)

Service User/Carer (5 to elect)

Staff working age adult (1 to elect)

Number of ballot papers despatched to members:

502 409 787 1066

Number of ballot papers returned: 116 68 109 147

Percentage turnout 23.1% 16.6% 13.9% 13.8%

Number of blank/spoilt ballot papers:

1 0 1 1

Due to not being an original as produced and despatched by ERS

0 0 0 0

Not accompanied by a valid Declaration of Identity:

0 0 0 1

Due to identifying the voter: 0 0 0 0

Due to having no mark or mark being unclear:

1 0 1 0

Therefore, total number of final ballot papers counted:

115 68 108 146

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6.3.3 The membership plan for the year ahead The tables below show the current demographic composition of our membership and our targets for the year ahead: BEXLEY 31st March 09

(actual) 31st March 10 (target) 2001 Census

Ethnic Group White 383 402 199,515 Mixed 11 12 2,856 Asian or Asian British 22 23 7,415 Black or Black British 43 45 6,245 Other 4 5 2,284 Not Stated 13 5,672 Gender Male 214 225 108,200 Female 262 275 115,787 Age Group Retirement age population 99 104 35,798 Young people (14-25) 67 70 37,818 BROMLEY 31st March 09


Ethnic Group White 500 524 270,652 Mixed 7 8 5,424 Asian or Asian British 12 13 7,524 Black or Black British 24 25 8,623 Other 7 8 3,119 Not Stated 11 6,735 Gender Male 221 232 145,378 Female 340 357 156,699 Age Group Retirement age population 122 128 504,44 Young people (14-25) 83 87 45,126 GREENWICH 31st March 09


Ethnic Group White 290 305 165,357 Mixed 9 10 5,850 Asian or Asian British 24 25 14,578 Black or Black British 100 105 23,787 Other 17 18 4,918 Not Stated 17 12,970 Gender Male 195 205 111,186 Female 262 275 116,274 Age Group

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Retirement age population 56 59 26,125 Young people (14-25) 43 45 38,811 We will encourage membership by promoting mental health and learning disability issues and the benefits of foundation trust status. We will adopt a variety of methods to reach the different target groups and will assess progress at regular intervals to ensure that as wide a membership base as possible is being developed and maintained. The methods used will need to be tailored to the appropriate groups. For a number of groups, an initial step of promoting awareness and understanding of mental illness and learning disability and relevance to the individual will need to be taken. It will be valuable to build on any current anti-stigma activity and may be possible to adapt mental health promotion campaign materials. Methods to raise awareness include:

Partner organisations: • Raise awareness via existing meetings. • Placing articles in partner organisations’ internal media. • Explore possibility of foyer displays/presentations at large meetings. Service users • Attend key service user and voluntary group meetings to promote membership

opportunities. • Develop communications tools to communicate with target groups: young

people’s conferences and magazine and membership materials and giveaways for people with learning disabilities

• Use direct mail marketing to all people using services, informing them of benefits of membership and give option to opt out.

• Encourage staff to discuss opportunity with service users and carers. • Work with service user consultants to explain membership to service users and

carers. • Develop discharge pack distribute with discharge questionnaire for service users

and carers which includes membership form and freepost envelope. Public • Raise awareness via media activities – e.g. events and promotion of activities in

schools. • Develop information on website and information pack. • Offer registration opportunities via freepost, free phone and web. • Utilise mental health promotion opportunities/materials offered by Time to

Change campaign and Shift programme. • Promote membership direct to public via:

o Links to local clubs and community organisations e.g. rotary clubs, pensioner clubs, ethnic minority groups, parent/teacher meetings.

o Health promotion campaigns via local media and events. o Stands in shopping centres, borough events etc. o Local authority media e.g. council magazines, citizen committees. o Open days/seminars offering information about membership and

mental health/learning disability issues. o Approach schools, pre-natal and parenting groups to provide mental

health information and promote membership opportunities.

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o Young person’s newspaper in partnership with the Priory School and Headliners young person’s media group

o Approach large local employers for endorsement and to promote membership opportunities to their employees.

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