Healthwatch Harrow Presentation

29th February 2016

1

Contents

• The Trust and Leadership

• Historical Context and challenges

• Getting a Grip – Priorities in 15/16

• Priorities for 16/17

• Strategy development

2

Rationale for creation of LNWHT • The 3 key arguments in support of the merger were:

• The need for critical mass to develop thriving hospital based clinical services, while facilitating the move of certain services to community and primary care settings,

• The need to reconfigure acute and other services across North West London as outlined in SaHF; and

• The need for a clinically and financially sustainable organisation fit for future purpose

• Strap line of “Stronger Together” recognised both organisations had weaknesses and risks prior to merger

The Trust The Ealing Hospital NHS Trust and The North West London Hospitals NHS Trust merged on 1 October 2014 to form London North West Healthcare NHS Trust.

We are now an integrated organisation that delivers acute and community care for the boroughs of Brent, Harrow and Ealing

• We serve a population of 850,000

• We employ 9,500 staff

• We have 1,240 inpatient beds

• We see on average 780 patients in A&E every day

• 2,000 patients attend outpatient clinics daily

• We provide 50 adult and 25 children’s community services across 6 boroughs

• Our annual expenditure budget is approx. £739m, with an income of £651m - £88.3m deficit

• Key player in Shaping a Healthier Future programme

4

5

• Operate from four acute hospitals on three sites – Northwick Park and St Marks Hospitals – Hot site, major acute and specialist

– Central Middlesex – Elective Centre in modern PFI, but underutilised

– Ealing Hospital – designated as a local hospital under SaHF, currently a DGH

• Community services operate from 25 community locations including Clayponds Hospital

– 9 community sites are owned by Trust, 3 are leased and for the rest, the Trust is a tenant

• Chronic underinvestment on Northwick Park site, with major backlog maintenance requirements

Estate

A new executive team by the end of 2015/16

Chief Executive Appointed 1 April 2015

Medical Director Charles Cayley appointed 13 August 2015

Chief Nurse Amanda Pye appointed 1 September 2015

COO Lee Martin appointed 1 November 2015

Director of Strategy Simon Crawford appointed 12 October 2015

CFO Jon Bell Interim CFO appointed 5th October 2015

Estates & Facilities Nigel Myhill appointed 7 September 2015

HR Director Claire Gore starting March 2016 Mark Gammage Interim Lead HR Advisor

Non-Executive Directors

2 new NEDs appointed August - October 2015 3 further vacancies to be filled – interviews in Feb 2016

6

• Improve our focus on safety, quality and performance

• Improve patient engagement, experience and satisfaction

• Develop and retain our workforce and empower staff to improve services

• Ensure financial sustainability – doing the right thing first time

• Plan for our future – engaging widely in setting our strategic direction

7

A new beginning - Corporate objectives 2015/16

• Consequences of the protracted merger process

– Leadership appointments delayed

– Integration benefits delayed

– Loss of short-term operational grip on A&E, RTT and cancer waits

• Uncertainty affecting recruitment

– Sector wide programme (SaHF), impacting future of Ealing Hospital and Central Middlesex Hospital

– Decommissioning decisions by commissioners

• Poor relationships with commissioners

• Significant organisational culture and value issues to address

• Financially Challenged

8

The Challenges

Page 9 Page 9

A new beginning Trust A&E performance

Weekly performance-upward trend evident since mid-January

50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

05

/04

/20

15

12

/04

/20

15

19

/04

/20

15

26

/04

/20

15

03

/05

/20

15

10

/05

/20

15

17

/05

/20

15

24

/05

/20

15

31

/05

/20

15

07

/06

/20

15

14

/06

/20

15

21

/06

/20

15

28

/06

/20

15

05

/07

/20

15

12

/07

/20

15

19

/07

/20

15

26

/07

/20

15

02

/08

/20

15

09

/08

/20

15

16

/08

/20

15

23

/08

/20

15

30

/08

/20

15

06

/09

/20

15

13

/09

/20

15

20

/09

/20

15

27

/09

/20

15

04

/10

/20

15

11

/10

/20

15

18

/10

/20

15

25

/10

/20

15

01

/11

/20

15

08

/11

/20

15

15

/11

/20

15

22

/11

/20

15

29

/11

/20

15

06

/12

/20

15

13

/12

/20

15

20

/12

/20

15

27

/12

/20

15

03

/01

/20

16

10

/01

/20

16

17

/01

/20

16

24

/01

/20

16

31

/01

/20

16

07

/02

/20

16

14

/02

/20

16

21

/02

/20

16

28

/02

/20

16

06

/03

/20

16

13

/03

/20

16

20

/03

/20

16

27

/03

/20

16

NWLHT A&E weekly performance - revised trajectory in line with 18 January 2016 bed capacity

standard All Types performance 2015-16 Trajectory All Types Revised Trajectory Type 1 Revised Type 1 Actual

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

05

/04

/20

15

12

/04

/20

15

19

/04

/20

15

26

/04

/20

15

03

/05

/20

15

10

/05

/20

15

17

/05

/20

15

24

/05

/20

15

31

/05

/20

15

07

/06

/20

15

14

/06

/20

15

21

/06

/20

15

28

/06

/20

15

05

/07

/20

15

12

/07

/20

15

19

/07

/20

15

26

/07

/20

15

02

/08

/20

15

09

/08

/20

15

16

/08

/20

15

23

/08

/20

15

30

/08

/20

15

06

/09

/20

15

13

/09

/20

15

20

/09

/20

15

27

/09

/20

15

04

/10

/20

15

11

/10

/20

15

18

/10

/20

15

25

/10

/20

15

01

/11

/20

15

08

/11

/20

15

15

/11

/20

15

22

/11

/20

15

29

/11

/20

15

06

/12

/20

15

13

/12

/20

15

20

/12

/20

15

27

/12

/20

15

03

/01

/20

16

10

/01

/20

16

17

/01

/20

16

24

/01

/20

16

31

/01

/20

16

07

/02

/20

16

14

/02

/20

16

21

/02

/20

16

28

/02

/20

16

06

/03

/20

16

13

/03

/20

16

20

/03

/20

16

27

/03

/20

16

Ealing A&E Weekly Performance

standard 2015-16 Trajectory All Types Ealing Type 1 Trajectory All Types performance Type 1 Performance

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

05/0

4/20

15

12/0

4/20

15

19/0

4/20

15

26/0

4/20

15

03/0

5/20

15

10/0

5/20

15

17/0

5/20

15

24/0

5/20

15

31/0

5/20

15

07/0

6/20

15

14/0

6/20

15

21/0

6/20

15

28/0

6/20

15

05/0

7/20

15

12/0

7/20

15

19/0

7/20

15

26/0

7/20

15

02/0

8/20

15

09/0

8/20

15

16/0

8/20

15

23/0

8/20

15

30/0

8/20

15

06/0

9/20

15

13/0

9/20

15

20/0

9/20

15

27/0

9/20

15

04/1

0/20

15

11/1

0/20

15

18/1

0/20

15

25/1

0/20

15

01/1

1/20

15

08/1

1/20

15

15/1

1/20

15

22/1

1/20

15

29/1

1/20

15

06/1

2/20

15

13/1

2/20

15

20/1

2/20

15

27/1

2/20

15

03/0

1/20

16

10/0

1/20

16

17/0

1/20

16

24/0

1/20

16

31/0

1/20

16

07/0

2/20

16

14/0

2/20

16

21/0

2/20

16

28/0

2/20

16

06/0

3/20

16

13/0

3/20

16

20/0

3/20

16

27/0

3/20

16

LNWHT A&E 4 hour 95% standard trajectory

National 95% standard All Types Trajectory All Types Performance

Type 1 Actual Type 1 Trajectory 2% Trajectory above T1 14/15 outturn

2% Trajectory above T1&3 14/15 outturn

A&E 95% standard Over the last few weeks the Trust have seen improvements in the national 4 hour standard for our emergency patients. On the 21.01.16, 22.01.16 and 07.02.16 the Trust achieved 95 per cent of patients being assessed, treated and discharged or admitted within the 4 hour standard. As the Trusts embeds our new processes, new beds and ways of working, the Trust will be agreeing further improvements to sustain performance. The Trust has also significantly reduced hand-over times for London Ambulance Service. This is a great achievement for all patients and their families. Actions completed: • Improvement plan in place supported by ECIP Team. • New modular beds opened on 18.01.16. • Implementation of Brent, Harrow and Ealing System Resilience

Group funded schemes funded until March 2016: • Brent and Harrow SRG 20 step down beds, frailty team,

discharge support team within A&E • Ealing SRG 12 additional low to medium acuity medical

short stay beds and additional 5 community rehab step down beds

Issue: • Specialist capacity for assessment - managed as part of

improvement plan • Late night breaches - managed as part of improvement plan • High levels of delayed transfers of care – managed jointly with

CCGs • Type 3 breaches at Ealing – to be managed jointly with Ealing

CCG

Page 10 Page 10

A&E Activity

A&E Activity • Despite the mild winter, attendances have increased across November to January with a total increase of 1,205 attendances in January compared to November • Ealing site experienced a large increase in Type 1 activity by some 437 attendances growth Actions to improve: • Working with SRG to reduce DTOC’s and patients who are medically fit for discharge • MDT group working on Regular attenders to A&E - to improve care planning and support their care at home • Working to improve the resilience of our rota twilight and nights when ED is particularly busy • Improving our bed access tools to, for example, ensure our community beds are fully utilised • We have improved our A&E escalation process – to ensure the FULL hospital supports A&E when they are very busy

EHT NPH LNWH

CMH-

UCC

EHT-

UCC

NPH-

UCC

LNWHT -

UCCs EHT NPH LNWH

Nov-15 3,389 8,083 11,472 2,987 5,437 8,650 17,074 8,826 19,720 28,546

Dec-15 3,661 8,095 11,756 3,247 5,667 8,927 17,841 9,328 20,269 29,597

Jan-16 3,826 8,109 11,935 3,194 5,608 9,014 17,816 9,434 20,317 29,751

TYPE 1 ACTIVITY TYPE 3 ACTIVITY ALL TYPES ACTIVITY

Page 11 Page 11

A&E Ambulances Performance

Ambulance interface: • 30 minute breaches have reduced by 57 from the previous month (660 breaches in December compared to 603 in January across the Trust). • Handover times have improved.

• There is a downward trend of arrival to handover times from 31 minutes to 14 minutes on average per patient within January • 60+ minute delays have improved. There was a total of 258 in last 8 weeks compared to 353 for same period in 2014/15

Financial Performance

• Historical deficits in legacy organisations

• £88m deficit plan in 2015/16 and significant risks to achieving this

• High growth in staff levels over last 2.5 years (£57m and 1,435 wte April 13 to Sept 15)

• 545 WTE new nursing posts established since Sept 13 (+160 beds and safe staffing)

• £16m in fines, penalties and metrics in 15/16 (lost income)

• One of our main CCGs in financial recovery

• Underinvestment in Estate - £34.9m backlog maintenance and limited capital availability

-5

12

187

216

293

721

1,424

-200 - 200 400 600 800 1,000 1,200 1,400 1,600

Other Non-Clinical

Other Clinical

Allied Health Professionals

Medical

A&C and Management

Nursing

All Staff

Change in WTE by Staff Group Apr 13 to Sep 15 (WTE)

£0.23m

£0.49m

£5.69m

£11.81m

£14.37m

£24.38m

£0.00m £5.00m £10.00m £15.00m £20.00m £25.00m £30.00m

Other Non-Clinical

Other Clinical

Allied Health Professionals

A&C and Management

Medical

Nursing

Increase in annual pay spend from 13/14 to Sep 15 (Total £57.0m)

12

Delivering 15/16 Control Total

• Weekly Divisional challenge sessions with strong clinical involvement

• Pragmatic review of initial CIP plans with focus on real delivery.

• Comprehensive review of all ward establishments and acuity and new agency controls implemented

• All non-clinical interims above Band 7 reviewed and reductions achieved

• Non-pay expenditure review with £2m additional opportunities targeted

• Income Maximisation Group established

• Significant improvement in run-rate and pay exit run-rate will be £18m better than out-turn

• Delivery of control total remains high risk - working with CCGs on system approach to delivering control total.

August 2015 Progress to December 2015

£700k per month spent on internal waiting list initiatives.

By December, this will is less than £50K per month.

Spend of £600k per month on non-clinical agency/interims.

Reduced the number of interims and will spend £2.2m less in the second half of the year.

Of the £6.8m corporate merger costs last year only £3m had been removed from the run rate. Estates & ICT spending more than last year.

Corporate will save over £3m in the second half of the year.

Agency spend from M1-5 was £4.8m per month - 12% of pay spend.

Agency M9 figure was £3.1m which equates to 8% of pay spend

13

Restructured board assurance arrangements- including

Cross-organisational divisional leadership teams in place

Divisional Clinical Directors part of the executive team

New Governance Structure in place

Finance and Performance

Integrated governance

Risk identification & mitigation

Learning from complaints and events

Patient safety, quality and experience

Strategy and transformation

New Executive Team appointed

Improvement Director and Team Appointed

Financial Recovery underway

Identified and starting to address income issues

Improvements to access including new bed capacity

Safe transition of maternity services

Achievements in 15/16

14

• CQC review (October 2015) – Quality summit planned March/April 2016 – Expect “Requires Improvement” – Warning Notice acted on and responded – Initial feedback being addressed

• Patient Safety – Increase number of serious incidents ( historic low reporter) – Focus on being a learning organisation – Open and honest reports – Engaging with patients and local communities

• Mortality – Systems and process in place – Working with TDA – Focus on understanding elective HSMR

Quality and Safety

15

Key Priorities for 16/17

• Address quality and safety issues highlighted by the CQC

• Maintain and improve focus on delivery of key performance targets (RTT, A+E, Cancer) and deliver the financial recovery plans

• Undertake a comprehensive programme of Organisational Development including: – Board development – Clinical engagement – Culture and Values – Integration – Collaboration and partnerships

• Improve business intelligence systems and resources, including SLR and Patient Level Costing

• Address estates challenges, working with SaHF, to support delivery of the Trust’s clinical strategy

16

Context to Strategy Development

London North West Healthcare NHS Trust was created on 1 October 2014 with the aim of creating a clinically and financially sustainable organisation capable of implementing safely the service changes envisaged through Shaping a Healthier Future (SaHF). Agenda driven by an increasing expectation of; - higher standards of care, improved access to senior clinicians

and diagnostics seven days a week, more integrated care closer to where patients live.

- increasing population growth with more prevalence of a frail elderly population putting different pressures on traditional models of healthcare delivery.

18

Major legacy issues

• Very hot acute site, operating at 98% + occupancy, poor estate infrastructure and backlog issues (clinical adjacencies, asbestos, heat and power supply), lack of historic investment i.e. IT, clinical equipment (x-ray, MRI, theatres) and support functions (pharmacy, medical records)

Northwick Park

Hospital

• Expensive PFI under-utilised with sector acknowledged trading deficit of £15m (original SaHF plan had an acknowledged lack of solution for CMH)

• A+E closure in Sept 14 reduced income and beds

Central Middlesex Hospital

• Smallest District General Hospital in London following loss of services and income

• Change in status under SaHF results in problems of retention and recruitment, had to invest in staff to maintain and improve quality

• Structural deficit of circa £15m (external review to validate)

Ealing Hospital

• Originally 3 separate services in former PCT’s with own legacy issues

• Historic under development and investment, poor relations with CCG’s, originally seen as opportunity but post merger lost significant elements of service

Community Services

19

Strategic vision for Trust

• Major acute/specialist site

• Prioritise capital investment c£120m to deliver CCU/Recovery c65+24 beds, 4 new Theatres, Pharmacy expansion and automation, MRI relocation, Endoscopy expansion/refurb, boiler replacement, Haematology relocation

Northwick Park

Hospital

• Large scale elective centre with UCC and community/primary care

• SahF business case capital c£23m to deliver; additional theatre capacity and improvements, Genetics' relocation from NPH, Willesden bed transfer, Endoscopy relocation on site, GP practice moving in

Central Middlesex Hospital

• Transition from small DGH to SaHF local hospital model

• Sahf business case capital net c£60m to remodel site to accommodate new models of care for; a local A+E incorporating a UCC, ambulatory care, and frail elderly unit, with access to diagnostics, outpatients, primary care, capacity for up to 104 beds (c 54 to support frail elderly pathway )

• Issue: A+E and critical care fully utilised and effective (transition safely!)

Ealing Hospital

• Develop to support acute/community integration with particular focus on support in home and to frail elderly

• Review and rationalisation of community premises to be undertaken

• Role in wider system transformation + models of delivery (ACP?)

Community Services

“Significant Financial support required for capital investment and OD transformation programme”

20

Clinical strategy development

• Centres of excellence for cancer; short-stay and ambulatory care, elective surgery; frailty services, reablement, well-being and EOLC; multi-disciplinary clinical education; Genetic and regenerative medicine

• Build on St. Mark’s expertise, tertiary services, specialist brand and charity

• Research partnerships for; surgical techniques, Genetic testing, regenerative medicine and clinical trials

• Develop community services integration with acute/primary care/local authority and voluntary services

Ambitions

Any questions?