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Operational Plan
2016/17
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Operational Plan for 2016/17
This document completed by (and Monitor queries directed to):
Name: Libby Walters
Job Title: Director of Finance and Resources
Email address: [email protected]
Tel. no. for contact: 01305 254661
The attached Operational Plan is intended to reflect the Trust’s business plan over the next two years. Information included herein should accurately reflect the strategic and
operational plans agreed by the Trust Board.
In signing below, the Trust is confirming that:
The Operational Plan is an accurate reflection of the current shared vision of the Trust Board having had regard to the views of the Council of Governors and is underpinned by the strategic plan;
The Operational Plan has been subject to at least the same level of Trust Board scrutiny as any of the Trust’s other internal business and strategy plans;
The Operational Plan is consistent with the Trust’s internal operational plans and provides a comprehensive overview of all key factors relevant to the delivery of these plans; and
All plans discussed and any numbers quoted in the Operational Plan directly relate to the Trust’s financial template submission.
Operational Plan Submission:
Approved on behalf of the Board of Directors by:
Name: Mark Addison (Chair)
Signature:
Approved on behalf of the Board of Directors by:
Name: Patricia Miller (Chief Executive)
Signature:
Approved on behalf of the Board of Directors by:
Name: Libby Walters (Finance Director)
Signature:
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1. Approach to Activity Planning
Dorset County Hospital NHS Foundation Trust’s (DCH) business plans are based on delivering the anticipated levels of demand in line with national quality and performance standards in the most cost efficient manner. Robust activity planning is therefore core to the development of the plan. During 2015/16 the Trust has experienced a reduction in the growth in its elective workload, particularly in the surgical specialties. This has also been reflected in a reduction in the growth of referrals into the Trust. The emergency workload, including emergency admissions and A&E attendances, has continued the growth seen in previous years. Outpatients have also seen growth, but at a lower rate than previous years.
2014/15 Activity
2015/16 Forecast Outturn
2016/17 Plan
2015/16 Growth
(%)
2016/17 Planned
Growth (%)
Elective 26,522 26,903 27,144 1.4% 0.9%
Non Elective
24,358 25,579 25,810 5.0% 0.9%
Outpatients 172,925 179,047 180,444 3.5% 0.8%
Emergency Department
42,367 43,747 44,139 3.3% 0.9%
National Operational Performance Targets
62 Day Cancer Standard The Trust is engaged in monthly meetings across the county with the CCG and other acute care providers to improve access to treatment for all cancer patients. The meetings are both system resilience oriented and have a practical breach analysis element to ensure each provider is delivering the best route to diagnosis and treatment. DCH is not the specialist centre for a number of the low number, high complexity cancer case treatments. Poole Hospital provides all radiotherapy, complex gynaecology and complex head and neck treatments. The Royal Bournemouth and Christchurch Hospital (RBCH) provides complex urological cancer care. Gynaecology, Head and Neck Urology and radiotherapy for prostate cases are pathways under extreme pressure at the tertiary centres. This will impact on the DCH ability to meet the 62 day standard. The work with RBCH on robotically assisted radical prostatectomies (RARP) has improved the timeliness of the treatment and we are starting to see more offers with a month of referral by the end of Q4. We will continue to work with RBCHto establish more capacity for the DCH clinician to support the county service with further operating lists at RBCH to further reduce and maintain access to RARP within 62days. Referral to Treatment There is a significant change programme for the Ophthalmology Dept underway with the whole team. It is acknowledged at a national level that there is insufficient capacity and
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consultant body to deliver the ever more complex treatments required for an aging population. The Gastroenterology team are managing a number of workforce risks relating to an inability to recruit to key posts and the impact of strike action in recent months. It is expected that the service will achieve 92% in Q1 but only if the impact of further strikes can be minimised or avoided. Emergency Department The Trust has launched an ambitious ‘Patient Flow’ Transformation Programme, which takes in delayed transfers of care, ED standards, ward reconfiguration, reduction in readmissions, ambulatory care and communications with other providers on transfers of care. DCH also requires system-wide support with these programmes as many reasons for delays to discharge and transfer are out-with the hospitals’ ability to immediately influence. Until these work-streams deliver smooth pathways into and away from acute care the pressure on ED will continue. In addition to ever increasing levels of ED attendance with a high degree of conversion to admission, we anticipate the level of delays in transfers, which are the equivalent of a between one ward and one and a half ward, to continue into Q1 and recognise that this will compromise the hospital’s ability to deliver this standard in the immediate future.
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2. Approach to Quality
As part of the standards for patient services detailed within the NHS Constitution and the CQC’s fundamental standards of quality and safety, the Trust is committed to the provision of safe, high quality care and achieving an outstanding CQC rating.
The Trust has had independent reviews undertaken in 2015 to seek assurance and provide recommendations into each of the domains of the CQC inspection programme. A CQC Inspection was undertaken 9-11 March 2016. The Trust is awaiting the final report and any further recommendations will be incorporated into the Quality Improvement Strategy for the Trust.
The Trust commissioned an independent review of its governance processes which has highlighted the need for more structured visibility of quality and safety metrics from ‘Ward to Board’. The Trust is currently in the process of implementing a mechanism for the display of this data to provide assurance at both divisional and executive level. The data collection has commenced on several of the ward areas.
The Quality Account priorities 2016/17 have been selected by the Trust and build on the recommendations detailed within the independent reviews as well as reflecting the National and Local commissioning needs and the top risks to quality identified internally.
The National CQUINs for this year include the promotion of staff health and well-being, the identification and early treatment of Sepsis and encouraging focus on antimicrobial stewardship.
Following initial discussions with our commissioners, local CQUINs, although not yet finalised, are set to revolve around the effective and safe transfer/discharge of patients, with a second CQUIN focusing on the impact of non-delivery of performance targets on patient care. The specialised CQUINs for the forthcoming year include HIV service specifications to have networked arrangements in adult and paediatric care and assurance that waiting lists/access policies ensure that the principles of the Armed Forces covenant as set out in the NHS constitution are applied.
Taking all of the above into account, the Trust will have three overarching Quality Priorities for 2016/17 with underpinning aims grouped into the 5 domains of the CQC (See below). These also incorporate the 9 Quality Account Priorities agreed for 2016/17.
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Robust analysis of
Mortality and SHMI
outlier data
Red
ucing the inciden
ce
and effective
managem
ent of those
patients admitted with
Sepsis/AKI
Med
icines
managem
ent
Standardisation of
equipmen
t, procedures
and pathways where
appropriate
Red
ucing Hospital
Acquired Pressure
ulcers
Im
proved m
ortality
surveillance and
reducing variation
Timely and accurate
provision of Electronic
Discharge Summaries
to primary care
Im
proving compliance
with NICE Guidance
Im
proving services for
Children and Younger
Peo
ple
Im
proving breast
feed
ing rates within
maternity services
Enhancing
antimicrobial
stew
ardship
Im
proved data
intelligence and
transparency
Im
proved analysis of
patient outcome data
Ensure lessons are
learned
and shared
across disciplines and
dep
artm
ents
Effective workforce
planning and
development of new
roles to m
eet needs
of patients
Im
plemen
tation of
improved discharge
processes
Im
prove iden
tification,
assessment and
referral of patients
with dem
entia
Coding of specific
inciden
ts or complaints
to im
prove End of life
Care
Red
uce waiting times
for patients
En
sure principles of
the NHS Constitution
are applied
Im
plemen
tation of
‘Seven Day Services’
Im
proving services for
patients with Learning
Disabilities
Advanced
communication skills
for staff supporting
patients and fam
ilies at
End of Life
Im
proving accessibility
of inform
ation to
patients
Timely and
compassionate
response to complaints
Promoting the health
and wellbeing of our
staff
REDUCING VAR
IABILITY
IM
PROVE
INFO
RMAT
ION, INTELLIGEN
CE AND
TRAN
SPAR
ENCY
TO DRIVE
QUAL
ITY
SAFE AND EFFECTIVE
ACC
ESS, ADMISSION, TRA
NSFER
AN
D DISCH
ARGE
EXEC
UTIVE
LEA
DS: Pau
l Lear (Med
ical Dire
ctor) a
nd Ju
lie Pearce (In
terim
Dire
ctor of N
ursing
and
Qua
lity)
SAFE
EFFECT
IVE
WELL‐LED
RESPONSIVE
CA
RING
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Approach to Quality Improvement
The Trust has invested and created a permanent service improvement team. The team identifies, supports, delivers and manages improvement initiatives generated from across the Trust, including; ideas from staff through the innovation scheme ‘Bright Ideas’; benchmarking information; projects identified through the Better Value Better Care programme; and direction from the Senior Management Team.
Seven Day Services
The Trust is working toward meeting the 10 Seven Day Services clinical standards; 5 will be met by March 2016 with the remaining 5 being delivered by March 2017. In July 2015, Monitor, the NHS Trust Development Authority and NHS England took advice from the Academy of Medical Royal Colleges about which standards would have most impact on reducing mortality. The Trust accepted that advice and adjusted its plans
By March 2016 Standard 2: Time to Consultant Review Standard 4: Shift Handovers Standard 5: Access to Diagnostics Standard 6: Access to Consultant-directed Interventions Standard 8: On-going Review
By March 2017
Standard 1: Patient Experience Standard 3: Multi-disciplinary Team review Standard 7: Mental health Standard 9: Transfer to community, primary and social care Standard 10: Quality improvement
Quality Impact Assessment Process
It is essential for the Trust that all opportunities for improving efficiencies are identified and delivered in a manner that allows sustainable change and allows the Trust to continue to provide high quality, compassionate care for future generations.
The Trust recognises that radical redesign needs to occur if efficiency and productivity are to be optimised and efficiencies delivered. A Better Value Better Care programme has been developed within the overall aim of driving service improvement to achieve maximum benefits whilst improving quality and efficiency. The development of the savings programme is an iterative process and the Better Value Better Care Board ensures best practice is being reviewed and embedded on a continual basis.
The approach outlined above has not yet been fully embedded. The potential scale of the efficiency requirements over the next 3- 5 years will be greater than the Trust can deliver without making further investment in the service transformation. This is currently being reviewed both internally and as part of the Acute Care Vanguard work.
Triangulation of Indicators
An integrated performance report is produced on a monthly basis to the Board of Directors. This report is a summary of key quality, workforce and financial risks to enable the Board to triangulate these risks. The key indicators are currently being developed and will focus on the delivery of the “9 Must Do’s” as set out in the National Planning Guidance.
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Quarterly divisional performance meetings have been developed in 2015/16 and these will continue throughout 2016/17. Dashboards that support the triangulation of information at a divisional and service level are being developed to enable this approach to be formally embedded throughout the organisation.
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3. Approach to Workforce Planning
An in-depth workforce planning exercise was undertaken for 2016/17 as part of the overall 2016/17 business planning process. Overall workforce plans were compiled by each of the Divisional Teams using feedback from the clinical leads in each area. .
When undertaking the workforce planning process for 2016/17 the two main considerations were the further development of seven day services and the provision of integrated care, in order to align with the five year forward view, the Dorset Clinical Services Review and the strategic direction of the Trust. Many of the identified developments involve a shift to community delivered services and new patient pathways to avoid admission where possible.
Governance of the workforce planning activity will be through the Strategic Resourcing Steering Board, chaired by the Director of Workforce and OD, which will report through to the Senior Management Team.
Reducing agency costs
A key focus of the Trust in 2016/17 will be the continued reduction in reliance on agency staffing. Good progress was made in this area in 2015/16, through the introduction of more stringent controls and the substantive recruitment of several key posts. Recruitment challenges still exist, but many of the new roles identified in the latest round of workforce planning, including an increase in Advanced Practitioners and the introduction of Physicians Assistants will assist in the longer term resolution of these issues.
Key performance indicators for workforce efficiency were established in 2015/16. These will be used to improve the management of annual leave and the recovery of contracted hours for all staff groups in 2016/17, and are monitored through the divisional performance meeting, and a newly formed resourcing operations steering group.
We are working collaboratively with neighbouring Trusts to achieve compliance with the new regulations on agency use. We anticipate the appointment of Tier 1 nurse agency providers at or below the capped rates in April. Recognising these challenges, the Trust will minimise the use of non-compliant agency staff through:
the development of alternative workforce models to resolve long-term gaps in Consultant and Junior Doctor rotas;
a comprehensive review of establishment levels to meet demand for one-to-one patient care and “flex” beds.
Agency workers will continue to be used as a last resort to ensure safe staffing, and we will continuously review compliant framework options.
The Trust has set the sickness absence target for 16/17 at 3.3%. This rate was achieved in five of the previous 12 months and is therefore deemed a realistic stretch target. Alongside the robust management of sickness absence, the approach the Trust will take to achieve this target is one of absence prevention via a greater focus on employee wellbeing. Existing wellbeing initiatives such as direct access to physiotherapy services will be extended to
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include the promotion of physical activity schemes and workplace training for managers regarding mental health promotion and support.
Local Education and Training Boards
The Trust provides current and prospective workforce data to Health Education Wessex as part of the Annual Workforce Planning Process. The collated data from all Trusts in the region is used to commission the training places necessary to assist with workforce supply. The Trust works closely with the local training providers/HEE to ensure that the training provided, including the placement opportunities within the hospital, meets the changing needs of the patients that we serve.
Triangulation of Metrics
Our division and Trust wide performance reports are integrated to identify linkages and causal factors. Through the establishment of a resourcing operations group, we are now triangulate roster efficiency data with absence data, demand data and agency usage. We will further develop this approach during 2016/17.
Risk Management
The overarching workforce KPIs, including vacancy levels, pay spend and sickness absence rates are scrutinised by the Finance and Performance Committee and reported to the Board on a monthly basis. Any key workforce risk areas that are not highlighted via the KPIs are also raised via these channels. At an operational level, progress against key workforce risk areas is monitored at monthly Divisional Team Meetings and reviewed by the Executive Team at quarterly Divisional Performance Meetings. The Resourcing Strategy Group meets on a monthly basis to review the recruitment and staffing plans on an ongoing basis, but with a particular emphasis on the winter period.
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4. Approach to Financial Planning
Financial Forecasts and Modelling The Trust’s forecast out-turn position for 2015/16 is a deficit of £5.4 million compared with the planned deficit for the year of £3.5 million. The deterioration from plan is as a result of increased expenditure on pay (especially nursing agency early in the year) and non-pay, as a result of the shortfall in CIP delivery and activity pressures in the hospital from very high bed occupancy rates throughout the year to date. Despite this high bed occupancy, there has not been a corresponding increase in the funding earned from commissioners, as a result of a change in case mix to more low value activity and the application of marginal rates to non-elective activity. Therefore the Trust under-performed against its planned contractual income.
The Trust does not expect to achieve its Control Total set by Monitor/NHS Improvement of an income and expenditure deficit of £300,000 in 2016/17. Therefore, the operational plan has been completed on the basis that the Trust is not being able to access the offer of additional Sustainability and Transformation Funding and has therefore excluded this amount from the plan for 2016/17. The planned position is based on delivering a £4.2 million CIP programme, at 2.61% considered to be stretching but achievable.
The table below summarises these figures:
2015/16
Forecast Out-turn
£m
2016/17
Plan
£m
Clinical Income 146.586 149.138
Non Clinical Income 12.399 11.793
Operating Income 158.985 160.931
Employee Expenses (102.930) (108.259)
Non Pay Expenses (59.016) (58.987)
Operating Expenses (161.946) (167.246)
Operating Surplus/(Deficit) (2.961) (6.315)
Non-Operating Income 0.085 0.063
Non-Operating Expenses (2.526) (2.881)
Surplus/(Deficit) (5.402) (9.134)
Memorandum information
EBITDA £m
EBITDA %
2.522
1.6%
(0.180)
-0.1%
CIP/Revenue Generation (netted above) £m
3.72 4.225
This will result in a requirement for formal cash support from September 2016 onwards. We continue to work with our Commissioners to improve this position and we have formally raised this issue with NHS Improvement. The Trust is continuing to work with the local
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health economy to find a Dorset wide solution based on a Dorset wide control total. These plans have not yet been agreed with NHS England. Costs The process for identifying future year costs has been through the Trust’s annual business planning framework which is predominantly activity and risk driven. It is anticipated that costs will increase by £9.29 million in 2016/17 as shown in the table below:
2016/17
Cost Increase - £m
Inflation (pay, non-pay & capital charges) 5.156
Developments/Risk mitigation 2.768
Impact of CNST changes 0.666
Non recurrent CIP in 2015/16 0.700
Total 9.290 Liquidity The Trust regularly reviews and updates its liquidity strategy to ensure the continuous improvement of the cash position, while supporting the capital investment programme. The Trust has a loan of £4.6 million from the Foundation Trust Finance Facility (FTFF), which is due to be repaid in March 2021.
The deficit position in 2015/16 and the planned position for 2016/17 are being managed by delaying the repayment of the loan, reducing capital expenditure in 2015/16 and 2016/17 and utilising existing cash balances. The forecast out-turn capital expenditure in 2015/16 is £3.9 million, £2.1 million less than the original plan of £6.0 million. The Trust has carefully managed its capital programme this year to partly mitigate the impact on its cash position of the deficit position being worse than plan. As part of the 2015/16 year end planning (in discussion with Monitor) the Trust has held £600,000 of capital schemes and delayed them into 2016/17.For 2016/17 the Trust has held its total capital plan at £6.156 million (equivalent to the depreciation charge for the year). The original plan was for a capital programme of £5 million in 2016/17. This has now been increased to £6.156 million to take account of the schemes deferred from the 2015/16 programme.
As noted above the Trust has not included its allocation of STF funding in the plan for 2016/17, and therefore the plan shows a deficit position of £9.1 million. The cashflow impact of this is that the Trust runs out of cash in September 2016 and will require £6.5 million of Interim Funding Support during the remainder of the 2016/17 financial year.
The table below highlights the opening and closing cash position as set out in the plan.
2015/16 2016/17
Opening Cash Balance
8.076 3.783
Closing Cash Balance
3.783 0.821
DH Interim Support Funding Received
- 6.500
Liquidity Days (3.9) (24.4)
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Continuity of Service Risk Rating For 2015/16 the Trust has a Financial Sustainability Risk Rating of 2 as a result of the level of deficit being incurred in the year. As the Draft Operational Plan has been submitted for 2016/17, with the Trust delivering a £9.1 million deficit, the resulting Financial Sustainability Risk Rating is a 1. The table below highlights the key figures within the 2015/16 and 2016/17 risk ratings.
31 March 16 - Forecast
31 March 17 - Plan
Capital Service Capacity Rating 1 1
Liquidity Rating 3 1
I & E Margin Rating 1 1
I & E Margin Variance Rating 2 2
Overall Financial Sustainability Risk Rating
2 1
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5. Medium to Long Term Sustainability and Transformation
Link to Emerging Sustainability and Transformation Plan
STP Footprint
Dorset County Hospital NHS Foundation Trust is part of the Dorset Sustainability and Transformation footprint which is being led by Dorset CCG. The other organisations within the footprint are:
The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust; Poole Hospital NHS Foundation Trust; Dorset Healthcare University NHS Foundation Trust; Primary Care and General Practice; and South Western Ambulance Services NHS Foundation Trust. Borough of Poole; Bournemouth County Council; and Dorset County Council.
The following Vision is emerging from the STP:
As leaders of our local health and social care system we are committed to improving health outcomes in Dorset, especially those with the poorest health. As part of this we want to see people better able to manage their own health and wellbeing, to have more care delivered closer to home - either in people’s own home, or at their GPs or using community facilities, with access to specialist medical help in a hospital when required.
Each aspect of our health and care system: GPs, hospitals, community teams and social care must be focused on maximizing the benefits to people and ensuring their experience of health and care services is as positive as possible. A key part of this will be having staff and resources across the system working closely together in an integrated way so that people, irrespective of whether they are adults, children or young people, experience a single service provided by a team with the most appropriate skills and experience.
All services must meet national quality guidance and provide the highest levels of quality and safety for our population. Our plans will see us provide:
Health and wellbeing services designed around people and not around structures or buildings;
A greater focus on preventing ill-health and promoting good health; Care delivered closer to home; Services which are sustainable - that is they can be delivered in a safe and
affordable way by appropriately skilled staff.
This vision will be for the benefit of all people in Dorset, regardless of gender, age, disability, ethnicity or sexuality. We are committing to making sure that people with mental health problems have the same access to high quality care as people with physical health problems, and older and frail people who live in Dorset, including those receiving end of life care are treated with compassion and dignity.
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We want the vision to reflect the importance of an integrated approach to health and social care which supports people to live healthy, safe and independent lives.
To achieve this vision we will work together as one system.
DCH Strategy
The Trust has recently reviewed its strategy and has set the following strategic objectives for the organisation:
1. Outstanding – we will be one of the very best performing Trusts in the Country delivering outstanding services for our patients
2. Collaborative – we will work with our partners across Dorset to design and deliver efficient and sustainable patient-centred, outcome focussed services
3. Integrated – we will drive forward more joined up patient pathways, particularly working more closely with and supporting GPs.
4. Enabling – we will engage with our staff to ensure our workforce are fit for the future 5. Sustainable – we will ensure we are productive and efficient in all that we do to
maintain our long-term financial health
The Trust’s operational and strategic plans are aligned to the emerging Sustainability and Transformation Plan and delivery mechanisms such as the Acute Care Vanguard.
The Trust’s operational and strategic plans are aligned to the emerging Sustainability and Transformation Plan and delivery mechanisms such as the Acute Care Vanguard. The most locally critical milestones for accelerating progress in 2016/17 to deliver the strategic objectives, meet the STP Vision and achieve the Triple Aim are as follows:
“One NHS Dorset” Acute Care Collaboration Vanguard: The Vanguard project will realise benefits through the better integration of services between the acute Trusts in Dorset;
Integration health and social care services: Development of integrated health and social services, through integrated care hub models;
Quality: Development of a Quality Improvement Strategy;
Efficiencies: Identification of additional commercial income and a review of Carter opportunities through the Better Value Better Care Programme;
Digital Pathway: Integrated care records across Dorset and the implementation of an Integrated Digital Care Record; and
Estate Utilisation: Review of opportunities to ensure the optimum utilisation of the estate.
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6. Membership and Elections
Dorset County Hospital has a membership of approximately 3,050 public and 3,400 staff and a Council of Governors comprising 16 Elected Public Members, 4 Elected Staff Members and 8 Appointed Members.
During 2015/16 governor elections were administered by Electoral Reform Services Limited. The ballot closed on Friday 10 July 2015, the results were as follows: West Dorset: 11 candidates from which 5 were elected. Turnout of 34% Weymouth and Portland: 11 candidates from which 4 were elected. Turnout of 42% Staff: 5 candidates from which 2 were elected. Turnout of 21% North Dorset: 1 candidate elected unopposed South Somerset/Out of Area: no candidates. Vacant post. Following the elections in July 2015 the Trust ran an induction programme for all new Governors and extended an invitation to attend to all existing Governors as refresher training. The Trust allows Governor to attend as observers at a range of committee meetings giving them the opportunity to both observe the meeting but also contribute at the end of the meeting where their questions and/or comments are welcomed. The Trust also runs quarterly Governors’ Working Groups and Governors attend the South West Governor Exchange Network. Each year the Trust runs a range of events aimed at facilitating engagement between governors, members and the public, and to provide a greater insight into the work of the Trust. Events during 2015/16 comprised of:
Members’ Events in July and November 15 175 Birthday Year launch event in May 15 and closing event in March 16 Trust Open Day October 15 AGM and AMM September 15
The Trust plans to hold the following engagement events during 2016/17:
Three Members’ Events Trust Open Day October 16 AGM and AMM September 16
In addition all Council of Governors meetings are open to members (4 per annum) and the Trust produces two newsletters and two e-bulletins per annum. The Trust has a Membership Development Strategy covering the period 2012/13 – 2016/17. The membership leaflet was revised in December 2014, to make the benefits of membership clearer and to make the leaflet more visually appealing. Membership pages of the Trust website were revised when the Trust launched its new website in January 2015. Membership pages are updated regularly with the latest events, election news and newsletters. The Trust has a Membership Development Committee which meets quarterly and is looking at increasing opportunities for face-to-face recruitment and the use of social media to promote events.
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Contact Details Dorset County Hospital NHS Foundation Trust Trust Headquarters Dorset County Hospital Williams Avenue Dorchester Dorset DT1 2JY Telephone: 01305 254641 Fax: 01305 254185 Minicom: 01305 254444 Email: [email protected] Website: www.dchft.nhs.uk Main Switchboard: 01305 251150 If you would like this document in another format or in another language please call the communications office on 01305 254683 or email [email protected]