Operational Plan 2017/18 & 2018/19 Pennine Care NHS Foundation Trust (Pennine Care)

Transcription

1 Operational Plan 2017/18 & 2018/19 Pennine Care NHS Foundation Trust (Pennine Care) 1

2 Pennine Care s approach 2017/18 & 18/19 Pennine Care believes that adopting a whole person, place based care approach will allow the organisation to drive service transformation at pace and scale, meeting the care and financial challenges ahead. Pennine Care s core purpose is to help communities to live healthy lives, acting with integrity and upholding our values. It means we will place the needs of patients and people at the heart of our service planning, working with local stakeholders to develop bespoke, place-based service offers that meet the needs of the six localities that we serve. Whole person care involves designing services in a way that provides holistic assessment and treatment, encompassing physical, mental and social health and wellbeing. It will help to improve quality of care, reduce fragmentation and duplication and have greater focus on prevention and recovery. In support of this, Pennine Care s overarching vision is to deliver the best care to patients, people and families in our local communities, by working effectively with partners to help people to live well. We believe that the best type of care for the majority of patients is provided outside hospital wherever possible, placing the person and their own home as a central part of future service delivery. If providers can begin to manage demand better, they can start to edge upstream and towards more preventative models of care. We will achieve this through our offer to the people and our offer to the place which is outlined within our five year strategy : Our offer to the people: We will create a positive experience by delivering care that: Empowers you to live well and stay well; Is high quality and evidenced-based; Is personalised and tailored to your needs; Is integrated and seamless; Is local, accessible and responsive. Our offer to the place: We will be a committed and trusted local partner by: Working in partnership, pro-actively contributing to the strategic and operational development of each town; Providing a bespoke service offer based on local needs; Sharing our clinical innovation and expertise; Assuring the safety and effectiveness of our services through robust governance; Providing a highly-skilled and motivated workforce to deliver person-centred care. This plan sets out Pennine Care s approach to progress our transformation programme in line with the Five Year Forward View and the local system s Sustainability and Transformation Plan (STP), whilst also continuing to deliver quality, financially viable services in line with the annual requirements set out by our local commissioning colleagues. Activity planning Pennine Care has developed its assumptions based on the specified commissioner contractual requirements for 2017/18 and 2018/19. We are currently commissioned by block contract across 15 CCGs, 6 Local Authorities, a range of NHS England contracts and associated contracts. A number of these contracts include indicative activity targets, against which performance is monitored. These are discussed and agreed as part of the annual contract negotiation process and monitored throughout the contract lifetime via a number of Contract Governance Forums. As part of recent contracting discussions with commissioning colleagues, there has been no indication that there will be any significant changes to contracted 2

3 activity. Consequently, the plan has been forecast based on current levels of activity for 2016/17. These assumptions are routinely monitored and adjusted in line with commissioner intentions, contract variations and tenders. The Trust is aware that procurement activities for current service provision are either already underway or will occur during 2017/18. As in previous years the planning assumption is that Pennine Care will retain these services but the Trust will review activity plans in the light of any changes in service provision that do occur in 2017/18 and 2018/19, and adjust activity plans accordingly. The Trust has a programme in place to review our mental health strategy, with a specific focus on bed utilisation, bed stock and location. This work seeks to balance the drive to a more community-based model of care, alongside the income-generation opportunities afforded by an appropriately utilised inpatient function. This work stream has formed part of the refresh of the organisation s Strategic Plan, which concluded in July Therefore, in developing the activity plan, the assumption that occupied bed days will remain static during 2017/18 and 2018/19 has been adopted. Capacity and Demand As part of our commitment to supporting service delivery with capacity and demand information, we have implemented Tableau - our business intelligence solution. This has enabled managers across the organisation to gain better insight to their service capacity and demand over time. Our service line reports provide a near live view of information on staffing levels and activity, from which services are asked to identify any specific capacity and/or demand issues. Where concerns are raised, the organisation has developed a suite of tools to support more in-depth analysis. We have continued to develop robust processes that will support a much larger piece of capacity and demand work when required. The process combines outputs from the tools defined, to provide an insight into the relationships between staffing configuration, current activity and service demand. This intelligence is then used as evidence for service redesign to reduce demand or improve utilisation of staff, or on some occasions as a case for increasing capacity. Work is at an advanced stage working with our commissioners to understand how our block contracts relate to individual service lines to identify if resources are allocated appropriately to meet demand. This will encompass areas where we are seeing growth in demand. We have been working with commissioners and NHS-I on specific pieces of detailed capacity and demand work around areas identified from the processes detailed above. Recently we have worked to understand capacity and demand within our MAS, EIP and IAPT services specifically these being the national Access and Waiting Times targets/key operational standards for mental health services outlined in the Five Year Forward View. As an organisation, Pennine Care is committed to looking at new ways to deliver care, including working with third sector agencies to support increased capacity. Partnership approaches form a key part of our commercial strategy and has some robust contractual examples in evidence of this e.g. with Age UK Oldham and The Big Life Group/Self-Help services. In summary, due to the processes in place, along with the detailed work done to understand any capacity hotspots, the Trust has a high degree of confidence that sufficient capacity is in place to deliver on the plan. Key operational standards There are no identified risks to Pennine Care maintaining its adherence to the applicable key operational standards. This specifically relates to the referral to treatment performance targets for our consultant-led pathways (Audiology and Community Paediatrics) and diagnostic waiting times for Audiology, as well as the specific Mental Health target for patients on CPA to be followed-up within 7 days of discharge from inpatient care. SOF The Trust s performance team has been fully engaged in the role out of the new Standard Operating Framework. In terms of the activity around this, the Trust is regularly attending the Strategy Leads 3

4 meeting at which the SOF has been trailed and introduced. The quarterly meeting has had the NHSI lead on SOF attending and briefing on the developments. When the shadow results of the first exercise were released in Autumn 2016, the performance team managers ran a session for the team on the impact of the new framework and how that translated into their operational service areas. Also, we have been regularly accessing the quarterly webinars run by HSJ. At the last webinar, senior leaders from CQC and NHSI were outlining the future alignment of the Improvement and Regulatory function. We also carried out a communication exercise to ensure key senior managers were briefed on the shadow results. Also, as a department the team s corporate arm has now fully reviewed all our external submissions that submit information which ultimately is used to generate the measures under the SOF. We are in the process of going through each return and introducing a standard operating procedure which specifies each stage of the process to generate, evaluate and quality check the information before it is released from the Trust. 7 day services Our mental health services provide a seven day a week service, delivered through our Access and Crisis and RAID (liaison psychiatry) frameworks. These cover all ages at the point of access for service users who are either new to the service and require assessment, or are known to the service and experiencing a crisis or need support. These services have full access to junior and senior medical practitioners to support their risk assessments and decision making processes. The service is 24/7 and is further enhanced by the delivery of the street triage scheme and helpline systems. This ensures emergency services and service users/carers that require help at any day or time, have immediate access to a trained practitioner who will be able to provide appropriate advice and support. Within our community services, we continue to work with commissioners to improve our out of hospital care offer, working in partnership with local stakeholders to improve integration and patient care. Ways in which we currently deliver on the out of hospital offer seven days a week include: Adult Community Nursing service (24/7) supporting people to be cared for in their own homes, preventing admissions and facilitating discharge; Community therapists in A&E - reducing inappropriate admissions, supporting timely discharge and follow up in the community; Intermediate care and enhanced intermediate care services (24/7) - strong partnership with social care staff based on site, facilitating effective packages of support in the community, including community IV services preventing hospital admission; Hospice Helpline (24/7) - for patients/carers and professionals, provides support and signposting to relevant agencies; Children's Community Nursing Team for children with acute, chronic, complex and palliative needs. This helps to reduce secondary care attendances, acute in-reach and increase discharges into the community. We will continue to work with commissioners to understand the demand for urgent and managed care 7 day services across both mental health and community services and how this can be supported within current financial envelopes. This will be developed through the locality planning process and in collaboration with patients, users and carers. In mental health services specifically, we are working with commissioners to understand the requirements of the 5YFV, specifically to ensure delivery of the mental health access and quality standards including 24/7 access to community crisis resolution teams and home treatment teams and mental health liaison services in acute hospitals. Work is on-going with commissioners to understand the implications of Core 24 RAID for services across the Trust footprint. With regard to Crisis 4

5 Resolution/Home Treatment provision, the Trust is currently undertaking a piece of work to benchmark current provision against the criteria outlined within the mental health 5YFV implementation guidance. This will encompass population size, caseloads size and current staffing skill mix. Whilst the Trust acknowledges the importance of crisis resolution/home treatment provision, it is also keen to jointly develop 24/7 proposals with commissioners in order to ensure that robust alternatives to admission are in place that encompass a range of community options for people. For example, a small pilot project in Stockport has demonstrated the potential to significantly impact on inpatient admissions through the provision of an out of hours Sanctuary model. The Trust is also an active participant in the Greater Manchester Child and Adolescent Mental Health Service (CAMHS) forum and one of our senior managers is currently leading a work stream for crisis support and 24/7 care for under-16s. Resilience plans In previous years, a number of system resilience schemes have been put into operation across a range of services which have included increasing community capacity to support an alternative to hospital based care, as well as increased capacity across mental health liaison services (with a focus into the Emergency Department) and increased bed provision, where appropriate, particularly in terms of intermediate care provision. Discussions continue with commissioners across our footprint with regard to long term and shorter term escalation plans. Any known activity has been modelled into the supporting activity submission Quality planning Section 1: Approach to quality improvement Dr Henry Ticehurst, Medical Director is the named executive with a lead for quality improvement. Pennine Care promotes effective quality governance within all service delivery and improvement. The Quality Strategy supports the Trust s on-going commitment to adhere to the Care Quality Commission s (CQC) fundamental standards of quality and safety. The Quality Strategy acts as a framework of accountability outlining the direction planned to achieve quality excellence in relation to: Patient Safety Patient Experience Clinical Effectiveness Pennine Care s Strategy promotes our approach to providing safe, high quality care measured against the five key questions in the CQC process: Are services safe? Are services caring? Are services effective? Are services responsive? Are services well led? The methodology implemented leading the Trust into its recent CQC inspection was outlined in the project plan Countdown to CQC providing us with a Trust-wide benchmark against expected standards in the key lines of enquiry, with targeted improvement plans for services where appropriate. The CQC has published PCFT s inspection report in December We are currently finalising the action plan covering the requirement notices contained in the report. PCFT was not issued with any enforcement notices from the inspection held in the summer of

6 The action plan is to be formally signed off by the CQC late January date to be confirmed for the Quality Summit held by the CQC, and subsequent sign off of the action plan. PCFT s action plan will be monitored on a monthly basis at the Trust s Quality group. The Quality Strategy will detail the action plan for the requirement notices plus a Showcasing Quality section to support the sharing of best practice across the services, acting as a vehicle to ensure learning is shared organisational wide and that practice is developed. The Trust operates a devolved business and operational management structure through a number of Divisional Business Units (DBU). Each of these units, led by the Service Director, is responsible for the delivery of high quality, effective and safe services. The DBU structure allows for wide ranging clinical involvement and engagement in quality governance and an ability to support continuous improvement at a local level within services. Each DBU is represented at the monthly Trust-wide Quality Group where the Quality Strategy and associated action plans are discussed and monitored in conjunction with senior clinicians. This group reports, by exception, to the Performance and Quality Assurance Committee, a formal sub-committee of the Board of Directors. This reporting structure promotes a greater connection from the ward to the Board. The DBU structure (there are 6 in total) also supports greater capacity and capability across services to embed quality improvement at a local level and to drive and implement sustainable change. The Trust has undertaken a review of the processes associated with the Risk Register; we have the process embedded at individual DBU level with a robust reporting structure to the Board. The Trust deploys a range of measures to demonstrate and evidence the impact of quality improvement work and initiatives. A set of outcome measures, both quantitative and qualitative is agreed for all quality improvement work streams. Benchmark data is collected and improvement metrics agreed in conjunction with clinical leads and service managers. This data collection is supported through a range of corporate service departments. Pennine Care has also commissioned independent evaluations of some quality improvement schemes where access to the required data has been problematic e.g. across organisational boundaries and clinical interfaces. Section 2: Summary of the quality improvement plan (including compliance with national quality priorities) The Trust s Quality Strategy (Quality Improvement Plan), and associated work streams will steer the development of the Trust Annual Quality Account. This process will commence in February 2017 and the Trust will engage with a number of stakeholders to agree the quality priorities for 2017/18: Service users and their carers; Commissioners; Health Watch; Staff; Governors. Our Quality Account contains the mandated quality sets that illustrate our performance against key national priorities and care standards. Our current account articulates our priorities for as follows: Sign up to Safety, including falls prevention; safe discharge transfer and leave; reducing hospital acquired avoidable pressure ulcers, and reducing delayed and omitted medications; Suicide Prevention; Collaborative Care Planning. 6

7 These priorities are monitored via the Quality Group with exception reporting to the Performance and Quality Assurance Committee (as outlined above). It is envisaged that the Quality Priorities for will continue with the identified areas from We are awaiting the publication of the guidance on the Quality Account. The Trust s Quality improvement plan will encompass the Quality Priorities and the actions from the CQC compliance/requirement notices action plan. Given the constraints of this return it has not been possible to provide the full details of quality improvement plans in relation to all local initiatives to be implemented over the next two years; however the action plan from the CQC inspection will cover areas including: Same sex accommodation; Medicines Management policy adherence; Implementation of supervision across all services; Use of different recording systems and the current mixture of paper and electronic notes in some services; Completion of care planning and risk assessment tools; Challenges associated with high bed occupancy. The Trust has chosen three areas listed in the guidance to provide more detail on: Pennine Care s Quality Improvement Plans in relation to National Clinical Audit (NCA) The Clinical Effectiveness Strategy is scheduled to be approved by the Trust s Quality Group in the New Year. The Clinical Effectiveness 2-Year Forward Plan has been written to capture individual objectives and plans for implementation, including Improve organisational use of national clinical audit outcomes. Communication mechanisms have been identified, to include the introduction of an Infographic Summary to cascade the key messages of national clinical audits across the organisation, together with the One-Page Report, which was introduced during 2016 to report national clinical audit results at a local level and enable effective action planning. A new Clinical Effectiveness Steering Group will be established during 2017 to oversee activity across the Trust, including the use of national clinical audit outcomes. The group will be expected to manage the development of CLEVER action plans and monitor the implementation of actions for quality improvement. Improving the quality of mortality review and Serious Incident investigation and subsequent learning and action The Trust has supplemented its Ulysses incident reporting form with an online questionnaire for reporters at the same time as reporting the death; this adds additional information available for both the front-line manager and central services to review the reported death (the additional questions have been informed by the gaps found by the Mazars Report). Central services review every reported death and decide whether or not to complete a Level 1 concise investigation; this decision is ratified at the weekly Patient Safety Improvement Group (Governance managers, Subject Matter Experts and Medical leadership are present). The Trust is working with other neighbouring NHS Trusts to establish equivalence with understanding and reviewing processes of mortality; a scenarios exercise was recently completed between three Trusts demonstrating a high degree of congruence despite using different systems. The Trust has established a Mortality Review Group to objectively review internal processes of decision making and deaths resulting in Level 2 investigations. The Trust has brought in Consequence UK to deliver a full cohort of training in RCA principles as an investment in frontline managers expecting to complete Level 1 investigations; the Trust is expecting to see an improvement in the quality of all investigations. In cooperation with another NHS Trust we are seeking agreement with Consequence UK to pilot a new method of case analysis which may see Level 1 investigations 7

8 replaced. The Trust is working toward a review of our investigation model after reviewing the results of the impact of the investment in the new RCA training; this may mean a change to a bespoke investigation team to deliver all Level 2 investigations where there has been a serious Patient Safety Incident and clear Duty of Candour exists for significant harm to the patient. Infection prevention and control The Trust has a statutory responsibility to comply with the Health and Social Care Act 2008: Code of Practice for the prevention and control of Healthcare-Associated Infection (HCAI) (Department of Health (DH), 2010). The Infection Prevention and Control (IPC) Service was audited by the Trust s internal auditors KPMG in January The review focused on a high level assessment of the governance arrangements in place around IP & C including policies and processes and the governance structure that exists around IP&C within the Trust. In addition, the auditors focused on two key areas pertaining to IP&C; clinical audit; and training and compliance. The Trust gained significant assurance with minor improvement opportunities. The 2016/17 IPC Work Plan details the quality priorities for 2016/17; this is monitored via the Infection Prevention and Control Committee. Section 3: Summary of quality impact assessment process The Trust has delivered financial efficiencies year-on-year since These have been achieved without significant disruption to service delivery and without detracting from the expectations of commissioners for quality and value. However, the current financial climate and changes in commissioning expectations mean the Trust has to change and develop a new strategy and associated Transformational Programme. The Board takes responsibility for ensuring that a full appraisal of the quality impact assessment is completed and recorded and that arrangements are put in place to monitor work going forward. Given the dynamic nature of the CIP schemes, this exercise is part of the Trust s core business and a feature of our Quality & Performance Governance Framework. This process has been informed in part by Delivering Sustainable Cost Improvement Programmes (Audit Commission/Monitor, Jan 2012) and Quality Impact Assess Provider Cost Improvement Plans (National Quality Board, July 12-Mar 13). All appropriate CIP schemes are subject to an assessment of their impact on quality. This is undertaken and led by the relevant clinical team and covers an analysis of patient safety, clinical effectiveness and patient experience. The Trust has developed a range of documentation to support this process, these include: Quality Impact Assessment; and Revised Service Line reports based on a core data set against CQC Care Quality domains and balanced scorecard approach. All CIPs are managed via a robust performance management process. The DBU structure is utilised to design CIP schemes with full operational management and clinical engagement. The Trust is also committed to co-producing plans with service user and carers. All CIPs require a named lead and in the majority of cases this will be a Service/Corporate Director. All CIPs are assessed for the impact they have on quality. This is underpinned through the robust baseline data collection prior to the proposed change, followed by the regular review of the dataset following the change programme. Regular reports on progress are then made into the Trust Assurance Forums and actions taken promptly in response to any variance. Plans are shared with Staff Side and this has resulted in changes being made to proposals, or change programmes taking longer to implement than expected, in previous years. 8

9 Additional scrutiny is also provided through the Quality Assurance Panels, with approval for all schemes via the Medical Director/Director Nursing AHP. Specifically the Quality Performance & Quality Review Panels, chaired by the Executive Director of Operations and Quality Group chaired by Medical Director, has a crucial role in reviewing, monitoring CIPs and Quality Governance Frameworks and where quality risks are identified, ensuring effective mitigation plans are in place. Externally all CIP Plans 17/18-18/19 will be co-produced via a series of joint CCG Locality Meetings prior to implementation, this approach will ensure a consistent understanding across our local health economy. In addition regular monthly reports are made into the CCG Mental Health and Community Quality Groups in respect of any impact on Clinical Effectiveness, Patient Safety and Patient Experience. Quality Impact Assessment process has continued to be refined throughout this year; in particular improvements will be made to assess more effectively the cumulative impact of schemes across a pathway. This framework has been formally audited by KPMG in March 2015; it received significant assurance with minor improvement opportunities. Findings and recommendations from this were fed into the Trust Audit Committee, March Section 4: Summary of triangulation of quality with workforce and finance Pennine Care has an integrated performance management framework. The framework includes integrated performance reporting from team to Board level covering: Quality; Activity; Finance; Workforce; Compliance. The performance reports contain key measures and indicators based on internal core standards, statutory and contractual requirements and a review of business plan objectives. In additional to the integrated reports, a revised assurance system has been introduced. Performance and Quality review sessions are held quarterly where each Divisional Business Unit presents an integrated performance and quality report to a panel made up of Executive Directors, corporate heads of service and a Non-Executive Director. The sessions seek to provide assurance against internal core standards, statutory and contractual requirements and business plan objectives and provide strategic support to divisions where required. Following the sessions, an overarching performance and quality report is produced for Executive Directors, prior to being presented at the formal Performance and Quality Governance Board Subcommittee. The new process enables and drives the use of information at all levels of the organisation, supporting the improvement of the quality of care and enhancing productivity. Workforce planning Workforce plans are developed at team, service, division and Trust-wide level depending on the needs identified. Support including the People Planning Toolkit and capacity and demand analysis tools are provided to services. Governance processes are in place to ensure that workforce plans are developed and agreed at the appropriate place. This includes: Work with staff side colleagues through our formal consultation processes for any organisational change, identifying impact on staff, supported by the Equality Analysis process; Quality review panels for all Long Term Financial Model (LTFM) planning using Quality Impact Assessments to triangulate service and staff impact; Board level sign off and review of the annual workforce plan, developed for Health Education England, to support education commissioning; 9

10 Work with Health Education North West using the Workforce Planning Tool and linking closely into the Clinical and Professional Education groups. This enables us to identify specific developments and needs and supports the commissioning of the education of our future staff. All plans are reviewed by appropriate service leads, Service Directors, Executive Directors/Board members as required. The workforce planning methodology for the Trust encompasses an annual review of our strategic aims, knowledge and context of service provision, CIP s, Sustainability and Transformation Plans, GM Locality Plans, Mental Health Strategy, financial and service activity, procurement, data analysis of current workforce, turnover in teams/roles, age profile and service banding structure. There are two distinct elements: internal planning: Divisional Business Unit People Plans, service modelling, transformation agenda and required organisational change processes, recruitment activity, skills gap and training; external planning: HENW projected educational demands, reflection of national activity across posts and National skills gaps. The Trust has recently developed and is now implementing a People & OD Strategy Strategic objectives have been identified for 2017/18 that summarise the key priorities to achieve these areas of focus and the strategic goal of being a Great Place to Work. To deliver the best care to patients, The Trust believes that a highly skilled, motivated and engaged workforce is essential for the organisation. The strategy has two key elements: 1) People - having a workforce that is effective and sustainable workforce that contains capable and skilled people 2) Culture Creating a healthy organisational culture through effective leadership for quality and service development It takes into account the significant changes in care delivery expected in the period at the local level and at the Greater Manchester level. This is managed by a People & OD Strategy Group with sub groups which meets monthly and monitors and assesses the Trust s performance against the work plan. This Group reports into the Trust wide governance process. Greater Manchester Devolution will continue to be a major factor in how Pennine Care is aligning its future services which will result in significant changes in the care model. Engagement with staff during this period will be essential to the effective delivery of services and design of the future model. Greater Manchester Locality Plans which are being developed across Greater Manchester and will form part of transformation bids as part of the STP. Within each of these Workforce strategies are being developed and programmes of work have started to be developed across GM to support the devolution process, this will create different employment models, roles, ways of working and organisational forms. The Trust continues to manage the impact of services being re-commissioned and how these will impact on our staff through possible TUPE transfers especially in CAHMS and Heywood, Middleton and Rochdale, a focus will be required to support the service model and staff during this period. The Trust is continuing to engage and is inputting into the new ways of working and organisational forms which we are expecting in the future. Recruitment plans have been put in place to continue to manage the on-going pressures on capacity in mental health and community services. New models both for recruitment, retention and role redesign have been actioned. The Trust continues to recruit, retain and develop the right people, right skills at the right time and develop its resourcing requirements based on clinical and business needs through an analysis of demand and capacity with schemes such as international recruitment; and continued focus on difficult 10

11 to fill posts such as district nursing and the mental health workforce, and the impact of the ageing workforce in these key areas. There are continued external pressures on agency spend for the Trust which include: meeting National Targets such as 7 day mental health services, contributions to the wider health economy especially with regards to local Acute Trust s winter pressures and reducing waiting times in A&E e.g. RAID, intermediate care beds etc. additional capacity commissioned by CCGs, an increased acuity of patients on the wards and future quality priorities from CQC report. The Trust has developed a comprehensive action plan monitored by its Strategic and Tactical Operations Bank and Agency Group, chaired by the Director of Workforce. The key areas addressed in the plan, encompass a range of actions within each, with SMART objectives are: procurement; quality review; reporting/business intelligence; e-rostering and workforce systems skills analysis; medical locums; recruitment and retention; bank staff, framework agencies above cap. This group reports to the People & OD Strategy Group and provides updates to the Executive team and Board through regular reports of progress against the plan and reduction in spend against trajectory. Financial planning Section 1: Financial forecasts and modelling The Trust is proactively involved across its six main localities in the development of Local Care Organisations and ensures that we are key partners in future reconfigurations. In constructing the financial plan, the Trust has held meetings with each of its local commissioners to ensure that all parties are agreed on the future direction of travel and that underpinning assumptions are clearly understood and form the basis of contracts. The Trust has submitted a financial plan that meets the requirements of the control total process. The key contractual issues, and consequentially financial assumptions, which underpin the construction of the financial plan include the following :- Mental Health Must Do s The Trust estimates this will cost 4m across all 5 boroughs. Agreement in principle has been reached to provide financial support with funding being released through a process of locally negotiated business cases. Where funding is subsequently not agreed then the Trust considers that the CCG will negotiate with Pennine Care and the GM team the approach that will be taken as targets will not be able to be delivered. As discussions are ongoing it has not been possible to model the impact of this investment within the financial plan however any impact is expected to be revenue neutral. Realignment of contracts baselines For several years CCG s have operated a risk reserve amongst each other that seeks to address cross subsidises within mental health services. The Trust is currently implementing a system of patient level costing and continues to work with commissioners in providing financial data to inform future commissioning arrangements, the financial plan assumes any realignment will continue to have an overall nil impact on levels of income received. Safer & Sustainable Staffing: Funding in the region of 1m is required from all boroughs in order to ensure safer staffing levels are maintained across the mental health acute inpatient wards (the Trust pump primed this investment in 2016/17). The financial plan assumes recurrent funding will be received from all commissioners, at this point only two of the five commissioners have included this funding within their contract offers, a clause has been included within the contracts of the three outstanding CCG s to conclude this issue before 28 th Feb Should this funding not be forthcoming the Trust will be required to reduce services in order to bridge the gap, this will require further consultation with commissioners. Stranded Costs: This plan assumes there are no major shifts in the provision of contracted services in the next two years, but should this be the case then any reduction in income would result in an 11

12 equal reduction of costs. There are currently 3 of the Trusts services (Cardiac Rehab, Podiatry and IAPT) out to tender by Heywood, Middleton and Rochdale CCG. The current income received for these services is approximately 4.5m and the associated restructuring costs associated with all 3 services is in the region of 0.5m. It is the Trust s intention that transitional funding would be sought from the CCG to support these costs for up to a maximum of 2 years however in the absence of a firm commitment to this principle the Trust has included this as a financial pressure within its plans. It should be noted that the inclusion of this 4.5m results in a discrepancy on the contract tracker submission. Efficiency savings: The Trust has set targets of 6.7m (2.5% of turnover), across all DBU s. This is the minimum required in order to address national cost pressures and achieve the level of surplus necessary to deliver the control total. In addition to this additional savings of circa 1.29m are required in order to address local cost pressures. The Trust has a strong track record of delivering efficiencies however with a reference cost index consistently below 80 the scale of the challenge is becoming increasingly difficult and it is recognised the majority of cost saving plans are likely to have a material impact on service provision, as a result the Trust is working to co-produce CIP plans with commissioners. Whilst schemes have been identified that would fully address the gap, the financial plan submitted is currently showing a shortfall of delivery in year of 2.4m, this reflects an assessment of risk to patient safety and the wider system pressures that would ensue if implemented. Following discussions with commissioners and NHSI the financial plan also assumes the receipt of 2m transformation funding, this is to support double running costs whilst the Trust works with commissioners to review the full programme budget costs for Mental Health Services with the aim of delivering longer term sustainable savings through economies of scale and redesign of Mental Health pathways using new models of care. Non Recurrent: The financial plan assumes only a small element of non-recurrent funding for clinical services as contract sign off has not yet concluded and there is no firm commitment at this stage. CQC Action plan: In negotiating the 17/18 contract commissioners have reviewed the challenges Pennine Care faces financially, alongside its recent CQC report with the Trust rated as Requires Improvement. An action plan is currently being co-produced; the financial impact has yet to be quantified and as such has not been included within the plan submission. Other Assumptions: In line with the technical guidance, this plan assumes that the Trust will receive the maximum of 2.5% CQUIN funding, 0.5% being earned for the delivery of the prior year control total however is held as a risk reserve within the Trust s balance sheet. In keeping with the draft plan, the final plan uses the inflation assumptions set out in the technical planning guidance issued by NHSI. Using these assumptions, the Trust has generated the two year plan which is delivers the following outputs:- A statement of comprehensive income (income and expenditure) - This shows that, the Trust is forecasting the delivery of CIPs of circa 8m, non-recurrent slippage of 2.4m is being supported by GM Transformation funding. The Trust does not currently have any schemes sufficiently worked up for delivery of the 2018/19 CIP targets. The plan submitted assumes schemes to the value of 6.6m will be identified in year and this supports the Trust in delivering the required surplus. The assumption regarding expenditure on agency staff is that the Trust will aim to reduce expenditure by circa 1m in 2017/18 and a further 1m in 2018/19. This should take the Trust to within 25% of the ceiling. This reduction is based on current spend and does not take into consideration any additional demands that may be placed upon the Trust to deliver, at pace, resilience schemes to alleviate wider system pressures (further detail is included within the workforce section). 12

13 The statement of financial position (balance sheet) shows that the Trust does not anticipate significantly altering the Non-Current Asset base across the life of the plan. It assumes that the cash available through depreciation charges will be used to fund a capital programme of the same value (approx. 3.5m per annum), with the addition of 0.5m PDC funding approved for 2017/18 and approx. 2.4m carry forward from 2016/17. The key movements in net current assets/liabilities are the increase in deferred income in relation to the CQUIN risk reserve and the utilisation of provisions (approx. 1.6m) anticipated in relation to restructuring costs as a result of the implementation of CIP schemes. The cash flow statement shows that across the two years of the plan the cash position increases from a forecast opening position of 11.70m to a forecast closing position of 13.16m in March The cash position in each year includes 0.5% CQUIN, earned in respect of delivery of the prior year control total. The effect of the assumptions made and resulting movements in the income and expenditure account, balance sheet and cash flow mean that the draft plan delivers a Use of Resources (UoR) rating of 2 in 2017/18 and a 1 in 2018/19. Section 2: Efficiency savings for 2017/18 to 2018/19 In line with previous years Pennine Care is planning to deliver its full CIP efficiency programme recurrently, although inevitably, as with other NHS organisations, not all schemes will commence on 1 April. Pennine Care has always thought broadly in terms of its CIPs and in previous years the schemes have incorporated service redesign, pathway management, back office review and streamlining of management structures. Additionally the Trust has also had a number of income generation schemes over previous years, particularly within mental health services. However, the majority of these opportunities are now exhausted and the Trust is facing the same challenges as many other Trusts in trying to develop efficiency plans that balance quality and safety as well as delivering the required level of savings. The locality plans directly affecting the Trust s range of services are in their infancy across all of the 6 localities that we operate in and therefore at this stage there are no firm locality centred plans that would deliver the CIP targets and also the gap resulting from local pressures, and so the Trust will potentially need to consider significant service changes/additional reductions to enable delivery of the overall savings required. It is anticipated that such changes would require external consultation and potentially overview and scrutiny from all associated partners and stakeholders. It should be noted however that to date discussions with local commissioners have shown that they are keen to work with the Trust to co-produce a savings plan that will deliver the overall aims of each locality. Plans drawn up to date for 2017/18 have been RAG rated and indicate that 2.4m (44 %) is high risk of non-delivery, with 1.2m (21 %) rated as medium risk and 1.9m (34 %) rated as low risk. Section 3: Capital planning The Capital Investment Plan has been developed in line with the service strategies, linked with local strategic estate plans across public service providers and the Greater Manchester Devolution agenda. The investment ensures we continue to provide Safe, Sustainable and Productive services, maintaining the Trust s current performance as a minimum. It targets priorities under fire, health and safety risk assessments plus investment into improving functionality, utilisation and rationalisation of the estate to support changes to improve financial and service performance. 13

14 The proposed Capital Investment Plan considers the requirements versus affordability and risk, the allowance for is 6.35 million including an element of carryover schemes from 2016/17 and 3.49 million in Investments include, but are not limited to: Improving building functionality and utilisation at Henry Square and community facilities as part of strategic estate work across our townships in conjunction with local authorities; Assist in premise disposal, lease terminations and rationalisation; Improvements in fire safety, patient safety including phased replacements of secure windows, curtain tracking and alarm systems; Replacement of medical equipment in dental, community and ECT services; Improving catering services in terms of quality and efficiency; Refurbishment of Parklands Ward, Royal Oldham Hospital; 136 Suite upgrades and development of sanctuary suite for adolescents; Mobile and agile working investment into technology to support community teams; Support minor improvement works aligned to PLACE & CQC inspections including improving outdoor space and creating Dementia friendly environments; Support the GM Devolution strategic estates work streams and One Public Estate agenda. Pennine Care is conscious of the need to long term plan and during the period of this plan will allocate resources to formulate plans and funding routes to support the investment into estate replacement and new business such as Female PICU beds and Child and Adolescent bed provision in mental health services. The estates plan will support the 5 Year Strategic Plan to ensure that any decisions made, both in terms of current estate and capital investment, are considered in line with the overarching strategy to allow resources to be invested in the schemes of most strategic and clinical value. Link to the local Sustainability and Transformation Plan (STP) In December 2015, the Greater Manchester Health and Social Care partnership (formerly the GM Devolution team) published an ambitious five-year plan for health and social care across the region Taking Charge which outlined five key themes to support the transformation of the region. Whilst Taking Charge sets the high level strategic framework for transformation, it is recognised that the delivery will be significantly influenced by the ten Locality Plans which are being developed to deliver a transformed system of health and social care within the ten boroughs of Greater Manchester. This holds with the STP s commitment to people and places, rather than to organisations. This philosophy has a strong alignment with Pennine Care s Strategic Plan based around the delivery of whole-person, place-based care. In the development of this new strategy, the STP was a crucial driver in terms of design and content and consequently there is a sense of strong alignment between the organisational and regional strategy. As Pennine Care works as a key provider partner within six of the ten GM boroughs overseen by the STP, we are closely aligned to the Locality Plan and Local Care Organisation (LCO) development plans within these areas, as well as maintaining a strong interface with the GM Health & Social Care Partnership team and a contribution to cross-cutting work streams. Within each of the six boroughs, however, the portfolio of services provided by the Trust differs. Equally, the approach adopted within the six boroughs in respect of both the Locality Plan and LCO development has been varied. As an organisation, we have therefore had to be adaptive in our response and contribution to each locality. Whilst a flexible approach has been adopted, we retain the same level of commitment to all localities within the Trust footprint. Consequently, just as our Strategic Plan has been influenced by the STP, it has also drawn on the emerging Locality Plans as part of our market assessment, to inform our direction of travel. At a more 14

15 micro level, within Pennine Care, the Divisional Business Unit plans will also continue to have a strong interface with each of the relevant Locality Plans. Considering how Pennine Care is supporting the key themes as set out within the STP, the table below summarises the key activities of the Trust: GM STP Themes 1. Radical upgrade in population health prevention Pennine Care contribution Active contribution and attendance at the GM strategy meeting for this theme. The Trust has developed a long term programme of work which supports population health, enshrined within a key strategic objective. This includes patient activation strategies, self-management support (including culture change programmes for staff and patients); enhanced use of technology and access to a Health and Wellbeing College offer. It is recognised that this is a long term piece of work but one which can enable and support a transformed and more resilient system. 2. Transforming care in localities Active contribution and attendance at the GM strategy meeting for this theme, supported by the development of investable propositions that demonstrate the return on investment that could be realised through more out of hospital care. Pennine Care has developed an evidence-based operational model which will be tailored to the requirements of each place. We believe that this is a comprehensive model that offers transformed care pathways to support out of hospital provision and whole person care, whilst retaining a bed based offer with a focus on restoring independence and self-management. 3. Standardising acute hospital care 4. Standardising clinical and support A place-based leadership structure will also be deployed during 2017 which will support the focus on place, effective relationships and partnership working to enable operational transformation. We are developing a refreshed mental health strategy that provides standardised treatment and care pathways, optimises bed utilisation and repatriates out of GM placements. We are also progressing transformational work streams within our mental health inpatient provision as part of Locality Plans and cross-gm with our mental health provider partners. This work to enhance our out of hospital offer and develop increased resilience and capacity within the community. Pennine Care is planning a review of support service provision to ensure both a value for money and fit for purpose provision that enables and supports the changing environment in which the Trust is operating i.e. a more localised, devolved and place-based approach. This will be undertaken early 2017/18. The Trust will continue to look at clinical efficiencies, enabled by our ability to benchmark across the organisation. 5. Enabling better care Improved access to service as part of a LCO approach will also be a major work stream across our footprint during 2017/18 and 2018/19. In support of the delivery of its Strategic Plan detailed enabling strategies have also been produced in respect of: Health Informatics; Estates; People and Organisational Development. 15