External Facing: North West Ambulance Service 2016/17 Operational Plan Narrative

Transcription

1 External Facing: North West Ambulance Service 2016/17 Operational Plan Narrative 1. Introduction As required by the planning guidance document Delivering the Forward View: NHS planning guidance 2016/17 to 2020/21, the Trust has produced an operational plan for 2016/17 that is consistent with the emerging local strategies. The plan acknowledges the financial, operational and clinical challenges, as well as opportunities for improvement; and this plan seeks to address these challenges, whilst taking advantage of the opportunities. The Trust Vision is to go from Good to Great by delivering the Right Care at the Right Time in the Right Place. This vision will be realised by the implementation of our Strategic Value and Compliance Goals: o Delivering Safe Care Closer to Home (SCCH) o A Great Place to Work (GPW) o Cause No Harm (CNH) o Finance o Quality o Performance The Trust Strategic Planning Framework supports the development of this Operational plan, ensuring the resulting plans align with the Trust values, strategic aims and goals; and with our assessment of the current market local health economy and other external factors. NWAS feel this operational plan takes advantage of the opportunities available to the Trust, building on our strengths, whilst addressing any weaknesses and threats; and will sustain the achievement and maintenance of high quality services that are underpinned by challenging but affordable and sustainable financial plans. These realistic but stretching plans also demonstrate the delivery of recovery milestones for core standards for ambulance waits where appropriate. 1

2 2. Paramedic Emergency Services - Approach to Activity Planning The demand and capacity approach for 2016/17 For Paramedic Emergency Services (PES), the Trust uses historical data to look at activity trends over a number of years to understand and predict future demand. Annual growth of activity is typically around 2.5% each year and this is used to forecast activity on a monthly basis. The Trust also looks at events which may increase demand such as bank holidays the festive season and major sporting events. Demand and Capacity modelling within NWAS utilises various systems. Within the Emergency Operations Centres, Erlang modelling for traffic intensity regards incoming 999 calls is utilised to ensure staffing levels reflect predicted activity levels. Within the response field, demand is looked at from historic trends over a number of years in overall demand and by the category of response. This looks at the See & Treat and See & Convey activity. It also takes into account the category of call from Red 1 to Green 4 demand. The demand is looked at monthly, weekly, daily and hourly by area and the expected increase is applied. In addition NWAS utilises Optima Predict simulation software to help with obtaining an informed decision regards any service changes both internally and externally. The baseline model mimics actual activity/performance and then a change in service can be simulated. The affect can be observed in various metrics, before any changes actually take place. The software capabilities have been shared with commissioners via the Strategic Partnership Board. The Trust has submitted trajectories calculated using Optima Predict modelling and Business Intelligence information for the most accurate trajectory we currently have. This is based on the key assumption that handover delays experienced in 2015/16 are reduced back down to the same level in early 2015 however this is largely out of our control. The Trust is also using assumptions shown below: It includes the full year effect of 111 and a percentage annual growth We deploy 98% of core resource plus 100% of the investment resource. It assumes that the current hear & treat and see & treat performance will improve The completion of short and medium term projects The Trust is looking at methods of increasing the performance and is working on several short and medium term projects. 2

3 Short term: Pre Determined Attendance (PDA) for all response codes, changes to Pathfinder tool to increase non A/E attendance outcomes. More and better utilisation of Acute Visiting Schemes, improved clinical support for operations and control staff, and a reduction in 111 ambulance response outcomes in collaborative work with the NWAS urgent care desk. Medium term: more recruitment and retention of staff, additional EMT1 staff due to a national shortage of Paramedics, and the introduction of response and convey service delivery model in various parts of the northwest. As per the NHS Provider guidance published 1st March which stated Identification of risks outside the direct control of the organisation, and how to mitigate, considering the shared understanding across the local health community, NWAS wish to highlight the following. The biggest inhibitor to performance currently is the hospital handover delay issues. If these were reduced to times experienced in early 2015 and the short and medium term actions are addressed, then the Trust believes that it will hit the required standards. Another important factor that would assist in NWAS delivering the target would be the introduction of the dispatch on disposition pilot currently in use in other ambulance services which would facilitate a more effective use of resources. These modelling assumptions are used to inform both the financial and the workforce planning, allowing us to triangulate these key areas and identify the impact and risks. To enhance the Trust s capacity to deliver the level of activity agreed with the commissioners, the Trust has a contract with a voluntary ambulance sector provider for a minimum daily level of nine urgent care service level resources. For requests over and above this level, the Trust can access private and voluntary ambulance sector providers through a framework arrangement hosted by an external company. Providers are assessed against specific criteria. They are available to the Trust via the framework, following a successful assessment. The Trust s activity plans are sufficient to deliver, or achieve recovery milestones for, all key operational standards (R1, R2, and A19): In order to support the achievement of the R1, R2 and A19 performance the Trust continues to focus on Admission Avoidance by increasing the Hear & Treat, and See & Treat activity; and reducing the See & Convey to Emergency Department (ED). This will be achieved by increasing assessment and treatment at home through access to community care plans and community based services, and reducing unnecessary conveyance by emergency service crews into emergency departments; providing the most appropriate patient care and experience. 3

4 Further associated benefits at hospital will be delivered through fewer attendances, improved throughput and improved ambulance turnaround times. By efficient management of ambulance resource the Trust will maximise the growth of patients receiving care closer to home by educating crews through effective triage as to the suitability of patients transported to hospital. As described previously the principle risk to the Trust achieving the national performance standards is the continually increasing hospital handover delays. A significant amount of resource is lost due to these extended times. This has a direct impact on the Trust s ability to get to patients in a timely manner. The management teams will continue to work collaboratively to develop local solutions to system pressures. There have been some innovative pilot s trialled which may lead to reduced handover delays. The Trust is actively engaged with NHS Improvement to identify mitigating actions to reduce delays and is activity contributing to planned workshops to review handover delays with the acute trust s and the local health economy. Winter resilience 2016/17 An essential part of NWAS winter preparedness is the formulation of a Strategic Winter Capacity Plan which draws together a number of standing and bespoke plans and procedures designed to underpin the wider preparations for winter increases in demand, changes in the activity profile and specific hazards or threats. This suite of plans consists of: NWAS Major Incident Plan Area Operational Winter Plans (including Emergency Operations Centres) Resource Escalation Action Plan (REAP) Clinical Escalation Plan Pandemic Influenza Plan North West Divert and Deflection Policy On-call and Deployment Guidance Departments Business Continuity Plans National Mutual Aid Plan Road Fuel Provision Plan These plans are supported by the functions below: ROCC Regional Operational Coordinating Centre provides an overview and a regional perspective on the day to day pressures, coping mechanisms and mitigating actions to provide assurance of NWAS continued capability to provide effective 4

5 service delivery. The ROCC will also look ahead to the remainder of the day, week and month and identify areas where supporting actions can be taken to reduce impact of pinch points. RHCD - The Regional Health Control Desk is co-located with the ROCC at Parkway, Manchester. It provides a monitoring and liaison function for the wider health economy, including the activation of the NHS England on call rota and notification of major incident alerts to Clinical Commissioning Groups (CCGs) and Acute Hospitals. The RHCD plays a key role in facilitating diverts and deflection requests at periods when Acute Trusts have exhausted all other actions. ALO Ambulance Liaison Officers play a vital role in building relationships within Acute Trusts, encouraging collaborative working, and at times of pressure coordinate a key NWAS present on-site to support NWAS crews delayed in handover. They also act as a link providing robust assurance that all internal escalation processes have been action in order to mitigate impact and support recovery. Assurance is required of the currency and utility of core contingency plans and to this end all are subject to a periodic review and approval process through Executive Management Team and Board of Directors. Internal Business Continuity Plans are subject to cyclical review, testing and exercising to ensure resilience on a regular basis and to provide assurance to NHS England. Additionally, standing Commander rota ensure that when required, an appropriate response can be made to occasions of performance challenge or incidents which threaten the maintenance of NWAS core business and critical functions. This can include the deployment of managers directly to Acute Trusts to aid patient throughput or reduce blockages and at strategic level, direct dialogue with senior hospital managers and/or Commissioners, Clinical Commissioning Groups (CCGs) and NHS England. Predictive demand analysis based on previous levels of activity shapes the allocation of resources and rota planning. In addition, the analysis includes the identification of key dates which will potentially produce high demand supports the focus on achieving maximum resource provision. The Resilience Team maintain a Mass Gatherings Register based on their contingency planning activities and liaison with other bodies which also aids the identification of the overall risk picture in terms of increases in activity and demand caused by sporting and other public gatherings. In order to minimise the impacts of severe weather challenges, all operational response vehicles have winter tyres fitted and half of all the Rapid Response Vehicle fleet are four wheel drive. For snow and flood related disruption, NWAS has long standing relationships with Voluntary Aid Societies and Private Ambulance Services who can provide support in the form of 4X4 ambulances and personnel able to access patients in difficult circumstances. 5

6 This augments the 24/7 Hazardous Area Response Teams, NWAS managers with 4X4 lease vehicles and additional off road vehicles which can be hired in at short notice. Widespread challenges will necessitate the establishment of multi-agency Strategic Coordination Groups (SCGs) and NWAS commanders are trained (and experienced) in working within such structures to provide a coordinated and effective response to the public in conjunction with partner agencies. Arrangements for unplanned changes in demand The Trust has arrangements in place with third party providers should there be a need to flex the resources at short notice. There are also national and local policies that can be implemented when demand increases over expected levels. Commissioning for Quality and Innovation (CQUIN) - the Trust plans include proposals for future CQUIN schemes. For PES these are focused on transformation priorities linked to our operational plan and STP's. The emphasis of Safe Care Closer to Home will continue focusing on the combined benefits made available from the collaboration of the urgent care service and 111, providing a Clinical Support Hub which is in line with the national guidance referenced below: for reduce rate of ambulance 999 calls that result in transport to A&E for all - integration and workforce development - improved system wide integration of workforce. The Trust plan also reflects the requirement to develop Staff Health and Well-Being schemes; and is working with the commissioners to agree the details. Conclusion to PES Activity Planning As per the NHS Provider guidance published 1st March which stated Identification of risks outside the direct control of the organisation, and how to mitigate, considering the shared understanding across the local health community, NWAS wish to highlight the following. The biggest inhibitor to PES performance currently is the hospital handover delay issues. If these were reduced to those experienced in Quarter 1 of 2015/16 the Trust believes that it will hit the required standard. The introduction of the dispatch on disposition pilot which would facilitate a more effective use of resources. 3. Patient Transport Services - Approach to Activity Planning 6

7 The Trust currently provides high quality non-emergency transport for NHS patients within Cheshire, Merseyside, Cumbria and Lancashire. Following submitting bids for the five new contracts which were put out to tender by the commissioners, the Trust was successful in being awarded the contract for four of the five lots, winning Cumbria, Lancashire, Merseyside and Greater Manchester and unfortunately losing the Cheshire contract. The existing contracts have been extended to cover the interim period between the original completion date (end of March 2016) and the new contracts start date which commence on 1 st July 2016; therefore the activity planning for 2016/17 has two elements: firstly ensuring sufficient resource to continue to deliver the current contractual requirements including KPIs for the existing contracts until July 2016, and secondly, utilising information provided by Arriva (the current PTS provider in GM), together with the modelling of resources utilising Autoplan software, to support the delivery of new and specific requirements for each of the four contracts going forward from July 2016 for the remaining nine months of2016/17. The Trust now commences a period of Mobilisation preparation whilst ensuring the current service continues to deliver the high quality standards as required the current contracts. Regular fortnightly meetings are held with the Commissioners Mobilisation Board where all the mobilisation plans, including activity modelling and planned resources are monitored as part of the routine assurance arrangements. Conclusion to PTS Activity Planning The activity planning for PTS for the new contracts will reflect the changes to the contract specification for Lancashire, Mersey and Cumbria, however the activity planning for Greater Manchester will be based on modelling and assumptions based on the information available from Arriva, therefore this will be closely monitored during the initial go live period, with plans for additional resource if necessary. CQUIN As part of the new contracts the Trust will agree a set of schemes that be funded by CQUIN. These schemes have yet to be agreed as they will not commence until the 1 st July in line with the contracts start date, however they are likely to focus on areas related to the 2015/16 schemes which, due to the unknown tender outcome at the time of agreement, focused on detailed analysis into key areas including long waits, patient experience and mental health support. It will be proposed that 2016/17 will focus on the implementation of the recommendations and lessons learnt from the 2015/16 schemes. 7

8 Approach to Activity Planning On 13 March 2015 the Trust was successful in being announced as the preferred provider for the NHS 111 contract for the North West. The Trust is the prime contractor for this contract in conjunction with our two sub-contractors FCMS and Urgent Care 24. The contract is over five years and commenced on 1 October The projected activity for 111 in 2016/17 has been agreed as part of the 5 year contract. As the 111 service in the North West is still bedding in, potential growth in activity for 2016/17 is unknown, consequently baseline activity values have been assumed. The service is still adapting to emerging activity trends which have impacted on our current performance levels, necessitating additional resource recruitment. Conclusion to 111 Activity Planning The Trust has experienced challenges achieving the KPIs for 111 and has undertaken a significant recruitment plan to ensure there is sufficient resource to ensure the achievement of the targets based on the activity planned, once the new recruits are trained and in post. CQUIN The key objectives for 111 for 2016/17 are centred on the development of systems and processes to support the virtual clinical support hub; namely senior pharmacist support, mental health outreach liaison, remote clinical technical access / integration. It is proposed to utilise CQUIN to trial and develop this approach during 2016/ Objectives and Innovation Service Delivery The Trust has reviewed the lessons learnt during 2015/16 and identified the key areas where further action is required, so in addition to the core business objectives to achieve all the financial, quality and performance standards and targets, the Trust is proposing a set of high level objectives for PES, 111 and PTS going forward. The Trust will also continue to horizon scan for opportunities to develop and expand its service and/or delivery footprint. 6. Communications Crucial to the achievement of all our plans is the provision of good communication and engagement. In addition to a wide variety of existing communication mechanisms the Trust plans to support PES through the continuation of the Team999 approach, developing more local messages and focusing on engaging with younger people. For 111 the Trust communications will focus on ensuring the public receive relevant messages regarding the 8

9 service. For PTS there is a dedicated work-stream where, working with the commissioners, we have developed a communications strategy and associated activity plans for all the five contracts. This is of course is mainly focused on the commissioning of the Greater Manchester contract but also includes the recommissioning of Lancashire, Mersey and Cumbria plus the decommissioning of the Cheshire contract. Strategic commissioning context in the North West A key component of the plans for the Trust is the joint partnership working with Commissioners. There are 33 Clinical Commissioning Groups (CCGs) in the North West, with Blackpool CCG acting in the capacity of Co-ordinating Commissioner. There is a Strategic Partnership Board chaired by the Chief Clinical Officer of Blackpool CCG covering the whole of the North West, supported in the governance arrangements by five county based groups led by local commissioners to consider local issues. The Trust is also heavily engaged in a number of significant health reconfigurations such as the new health and social care system being developed as part of Greater Manchester s devolution strategy. There are currently over 47 major reconfigurations across the five counties in the North West, all of which impact the activity planning for the Trust together with our ability to give assurance of delivery to recovery milestones. Major system changes include: Vanguards, Healthier together and the Cumbria success regime. 7. Approach to Quality Planning The NHS defines quality as having three dimensions; Clinical Effectiveness, Safety and Patient Experience. How we will deliver improvements in these areas is described in our Quality Improvement Strategy Supporting the delivery of the Quality Improvement Strategy are the Clinical Strategy and Safety Improvement Plan (incorporating our Sign Up to Safety pledge). Together, these are designed to deliver our statement of purpose Right Care, Right Time, Right Place, and our strategic quality goals, which are to Do no Harm, be Great Place to Work and provide Safe Care Closer to Home. The aims of the Quality Improvement Strategy are to: Continuously seek out and reduce harm (Sign Up to Safety pledge) Achieve the highest standards of reliability of care Listen and respond to what matters most to patients Deliver Safe Care Closer to Home in partnership with local health and social care. 9

10 The aims of the Clinical Strategy are to: Provide a safe primary triage system Provide a bespoke, clinically appropriate response Provide safe care closer to home, which fully meets the patient s needs Understand our population, promote self-care and support prevention. The Trust is committed to the national Sign up to Safety Campaign with the continued ambition of halving avoidable harm over a three to five year period, using the following five core pledges: Put Safety First Continually Learn Honesty Collaborate Support The Quality Improvement Strategy describes our intent to grow our quality improvement infrastructure and capacity from the front line through to the Board. This is an important step in our quality improvement journey and is described in more detail below. The Clinical Strategy describes actions we will take to deliver our clinical quality priorities working in partnership with our staff, patients and commissioners. The Safety Improvement Plan 2015/20, developed as part of the Sign up to Safety Campaign, describes the year on year actions that we will take to reduce harm to our patients and our staff Quality Priorities In 2016/17 our quality priorities are to: Improve performance against the Category A response requirements Reduce clinical risks in the 999 Control and Triage environment Increase the number of patients looked after safely at home Plan and deliver interventions to ensure parity of esteem for Mental Health Patients. Key Milestones and Performance Indicators 10

11 The growing volume of 999 calls has the potential to result in increasing clinical risks for patients. In order to reduce clinical risks in the 999 Control and Triage environment we will introduce clinical supervisors in our Manchester EOC during 2016/17 as one of a range of improvement measures that have arisen from learning from serious incidents. The Trust will focus on two clinical areas to increase the number of patients left safely at home the numbers of patients left safely at home. Patients suffering from Sepsis are a focus of concern nationally and we know that the care pathway has not been performing to a reliable standard. During 2015/16 we piloted a Sepsis recognition tool, researching the sensitivity and specificity of this against outcomes for 259 confirmed cases. Our objective this year is to scale up this work, developing the associated learning packages, rolling out the tool and monitoring against a new clinical performance indicator. Milestones for this are in development. Frailty and dementia affect increasing numbers of the population and often lead to contact with emergency services. Our objective this year is to develop and pilot a Three Step Safety Assessment tool to enable urgent safe referral to local services. We already use a physiological safety tool, Pathfinder, to which we propose to gain evidence for adding a psychological and functional safety step, ensuring parity of esteem and assuring the appropriate baseline is considered for these patients. Improving the identification, consistency and safety of responses to patients with dementia is a quality objective within the NHS 111 service for 2016/17. Where the Trust has concerns relating to quality, plans have been put in place supported by our commissioners to reduce the impact of these. Quality Improvement The quality improvement approach and framework that NWAS will use is based on the Institute of Health Improvement (IHI) Model for Improvement and starts with 3 principal questions: 1. What is it we are trying to achieve (what s the aim/goal)? 2. How will we know when a change is an improvement (what are the measures)? 3. What changes can we make that will result in improvement (what are the activities or projects)? 11

12 The Plan-Do-Study-Act (PDSA) cycle will be used as the process for rapidly testing changes on a small scale within real work settings. The PDSA cycle will guide the test of a change to determine if the change is an improvement, including further cycles to refine and improve. NWAS Improvement Framework The Trust will use an adaptation of the IHI s Breakthrough Collaborative Series (BCS) Improvement Model which is designed to create a structure in which improvement teams are coordinated and can easily learn from each other and from recognised experts in topic areas where they want to make improvements. NWAS Quality Improvement Governance The executive lead for quality improvement is the Director of Quality. The executive lead for the Clinical Strategy is the Medical Director. Following a review of the Boards performance against the Well Led Governance framework, a score of 3.0 was agreed. Quality improvement priorities and goals are described in the Quality Improvement Strategy and Clinical Strategy. Quality risks are identified, mitigated and assured via a robust Risk management system which includes review of key quality risks by the Board, Quality Committee and Executive team. The composition of the Board is balanced with expertise in Clinical Quality, Governance, Finance, and Operations. Quality is reviewed, and challenged at every meeting of the Board of Directors, supported by a performance management framework from the Board to local management teams. Quality improvement is embedded in the three service lines via Quality Business Groups (QBG) which are responsible for the oversight of and management of quality improvement. During 2016/17 the QBGs will be supported in the use of the IHI Improvement Model and BCS Framework. Progress against annual Quality Improvement milestones and performance indicators will be reported to and performance managed by the Executive Management Team monthly. An assurance report will be received by the Quality Committee bi-monthly. Risks, mitigations and assurances will be reported to the Board. Oversight of risks to delivery of the Clinical Strategy will be undertaken by the Clinical Governance Management Group (CGMG), and jointly with Commissioners at the Commissioning Quality review meetings. Measuring and Monitoring Safety 12

13 During 2016/17 NWAS will complete a 2 year large-scale Quality Measurement and Improvement Project in partnership with AQuA and the Health Foundation. Learning from the project includes review, development and testing of a new range of quality and safety measures during 2016/17, for implementation in Quarter 4. The measures will provide the Board of Directors and managers with assurance regarding the quality and reliability of care being delivered to patients on a day to day basis. These measures will be sufficiently balanced and have the ability to identify the impact that any improvement activities, service developments or strategic decisions may have on clinical quality. From an individual clinician perspective, measures will provide sufficiently granular information to ensure learning and development. For managers, the measures will provide a balanced view of individuals, teams and areas which support appraisal processes and enable more targeted improvement activities, with an emphasis on reliability of care. Quality Impact Assessments The Quality Impact Assessment (QIA) Approval and Review Procedure is an integral part of the Trust s Performance Management and Assurance Framework and has been developed to support the Trust s cost improvement programme (CIP) and other programmes that drive significant changes to service provision. The Medical Director and the Director of Quality (collectively the Quality Directors) have specific responsibility to review and sign-off all QIAs and report assurance to the Quality Committee and, where appropriate, the Board of Directors on the quality impact of the overall CIP Programme/Provision of Service change. This allows us to triangulate the potential impact on quality, performance and finance. The management of the annual CIP process relates to both delivery of the in-year programme and planning programmes for the following financial year. The Trust s CIP Steering Group meets monthly to review progress and plans, providing assurance to the Quality Committee, Finance Investment and Planning Committee and onward to the Board of Directors. Reports to these committees are available as evidence. 8. Objectives and Innovation Quality Directorate Goal Objective Planned Outcome To be the safest Ambulance Service in Contribute to the reduction of harm to patients who are suffering a mental health crisis by the end of March 2017 % decrease in the number and severity of reported mental health related patient harm incidents 13

14 Directorate Goal Objective Planned Outcome the UK 9. Approach to Workforce Planning Contribute to the reduction of harm to patients from the administration of medicines by end of March 2017 Support activities to reduce harm to patients, who have been re-contacted within 24 hours, by the end of March 2017 Reduce harm to staff and patients from manual handling injuries by March 2017 Continue to reduce the total number and value of claims reported to NHSLA each year Develop a Quality Improvement framework by March 2017 Develop an competency investigation framework BY March 2017 By March 2017 develop a robust process for capturing and promoting Trust learning % decrease in the number and severity of reported medication related patient harm incidents % decrease in the number and severity of reported re-contact within 24 hour related patient harm incidents % decrease in the number and severity of reported manual handling related staff and patient harm incidents % decrease in the number and value of clams reported to the NHSLA An approved documented Quality Improvement Framework for the Trust An approved documented competency investigation Framework for the Trust An approved implemented learning process for the Trust Workforce Plan Development and Governance The Trust takes an integrated approach to workforce planning through engagement with service lines, clinical leads and Finance to ensure a holistic and robust approach to planning. Agreed plans are monitored with service lines and Finance on a monthly basis so that developing trends can be identified and addressed. This means that the planning process is an evolving one with plans being rolled on and adapted throughout the year so that there is always a detailed view of 12 months ahead within the context of the overall 5 year plan. Plans also take account of clinical strategy and developments, particularly around Hear and Treat and See and Treat and the impact of reconfigurations of services. The Trust is heavily involved in local developments such as Greater Manchester Devolution and the associated Heathier Together developments, North Cumbria Success regime and Healthy Liverpool but the impact of these developments on our own workforce is not sufficiently clear to have incorporated them into plans at this stage. Plans do take account of specific workforce initiatives for but it is a year of stabilisation for the Trust in the Paramedic Emergency Service (PES) following significant investments in increased resources during 2015/16. 14

15 The Trust continues to assess the impact of the deployment of additional resources on performance and quality and will develop and adjust plans during 2016/17 to ensure the most effective skill mix and use of resources. The Paramedic Emergency service uses the Optima system to model activity and resource deployment. The key challenge remains Paramedic recruitment and retention and there are a number of initiatives aiming to address this, including international recruitment. The focus in the Patient Transport Service will be mobilisation for the new contract including the TUPE out of staff in Cheshire and the TUPE in of staff for the Greater Manchester contract. The focus in 111 is continued recruitment to address emerging activity demands following mobilisation and then a focus on moving the balance between agency and permanent staffing which is outlined below. The TDA 1 year and 5 year plans are submitted and approved at Trust Board and the 5 year plan is reviewed regularly through our Integrated Business Plan in preparation for our Foundation Trust application. The Board, Executive Management and senior management teams receive monthly reports on workforce data which demonstrates the position against planned establishment and more detailed reports against the workforce and recruitment plans are received and challenged at Performance Committee. Ad hoc reports are also provided on specific aspects of the workforce plan to Executive Management Team, Committee and Board as required, for example, on the Paramedic position which remains a significant risk to the trust. These processes ensure effective and robust governance arrangements are in place. Unfortunately there are no national tools to assist Ambulance Trusts in triangulating quality, performance, finance and workforce data. However, the Trusts Integrated Performance Report enables an overview of all key quality, performance, financial and workforce related indicators across the Trust and the interaction between those elements of performance. This is reviewed monthly by the Trust Board. The Board also receives an in depth analysis of workforce issues on at least an annual basis, which includes integrated analysis of resource usage and deployment in the context of performance and quality. All Cost Improvements (CIP) have a Quality Impact Analysis completed and signed off by Director of Quality and Medical Director. These are reported to Board Committees and Trust Board along with the risks to quality and performance associated with the CIP. The Trust has a robust approach to risk management with workforce risks being managed at appropriate managerial levels. Risks are reviewed regularly by senior management teams 15

16 and significant risks are escalated to the Executive Management Team and Board for oversight. These are reviewed monthly by the Executive Management Team and Trust Board and are also reviewed in more detail through the relevant linked Board Committee. There are a number of workforce related risks which have Board scrutiny, including Paramedic turnover and recruitment, the potential impact of Paramedic Evidence based Education Project (PEEP) on the paramedic supply line and sickness absence. Agency, third party usage and e-rostering The use of agency staff within an ambulance sector setting is very different to an acute and the following sets out the position in key services lines, including how the trust is responding to the revised nursing agency rules to mitigate any emerging risks and how e-rostering is used to enhance efficiency: Paramedic Emergency Staff there is no use of agency staff for frontline deployment within this service line. Third party providers are utilised in a limited way to help address peaks in demand but this has been managed down as the recruitment plans for 2015/16 have been delivered. Cost and quality has also been improved through an effective retendering process for third party provision in 2015/16. Plans for 2016/17 will continue to include an element of third party usage in order to enable flexibility of response to surges in demand. This service line has an effective E-rostering system which is utilised to ensure efficient rostering of staff and in 2015/16 has been used very effectively to help improve management information and target reductions in absence and therefore availability of resources. There is also extensive use of a resource deployment modelling tool. Patient Transport Service use of agency staff in this service line is restricted to use within call taking. Regular agency staffing has been maintained in this area over 2015/16 because of the pending tendering process and the uncertainty over future requirements. The next few months, including early 2016/17, will see permanent recruitment into roles to reduce reliance on agency staffing as part of the mobilisation of the service for the new contracts which commence on 1 st July Plans for 2016/17 will continue to include a balanced approach to the use of third party providers and volunteers where they can provide a more cost efficient service and this has always formed part of the proposed service delivery model agreed with commissioners. E- rostering is not in use within this service line but consideration will be given to the extension of the current system in use in PES. 111 the 111 service is currently exempt from the cap on nursing agency use and also has had a short-term exemption for the use of an agency which is not on the framework. 16

17 The exemption has been given in recognition of the unique position of 111. The exemption relating to the use of agencies not on the national framework expires at the end of March 2016 and notice has already been given to the provider that we cannot continue to use them as a provider. The impact in terms of numbers is fairly small and we are engaging both with agency partners and the individuals affected to find an alternative solution. A proportion of establishment is delivered through agency partners for both nursing and call taking. The Trust has also been using an agency to trial an alternative approach to the non-clinical management of lower acuity calls which will be evaluated with a view to a permanent change to skill mix. The Trust has only recently mobilised the service for commencement of a five year contract to deliver 111 services across the North West and prior to this was a stability partner. The agency model has therefore been inherited but it is planned to reduce reliance on agency staffing over time. The service is however, still having to adapt to emerging activity trends with additional baseline recruitment which will be the focus for the first part of 2016/17 with plans then focusing on the reduction of agency arrangements. There are however difficulties in recruiting clinical advisors, as both the nursing and paramedic recruitment markets are challenging, so plans need to be resilient enough to manage the risks associated with a change in the balance between agency and permanent staffing. It is planned to roll out a new e-rostering system in 2016 which will assist in improving the efficiency of rostering arrangements and help to reduce agency staffing usage but the service line already uses Erlang modelling which is a recognised call centre modelling tool to effectively plan resource requirements. Alignment with local education and training board (LETB) plans The Trust has worked closely with Health Education England (HEE) and the associated LETB to ensure improved understanding of the challenges facing the ambulance sector, the potential impact of Paramedic Evidence based Education Project (PEEP) proposals and the impact of emerging opportunities for the Paramedic workforce in both private sector, and public sector acute and primary care settings. This has included senior level meetings and presentations direct to the LETB to raise awareness of the risk of restrictions on the supply line to future workforce plans and delivery. As well as the HEE workforce plan submission, the Trust has worked closely with Health Education North West (HENW) to keep them abreast of emerging trends such as increasing 17

18 paramedic turnover (arising mainly from increased opportunities for paramedics in acute and primary care settings as a response to the challenges of nurse recruitment) and the impact on future commissioning. In additional commissions were agreed including a move to a spring and autumn intake in order to help to even out recruitment across the year and the impact of some of this can be seen in plans. Significant work has also been done to help secure future supply lines. The Trust s strategy is to maintain a healthy balance between internal development of staff to Paramedic status and graduate intakes because this is shown to support effective retention of newly qualified paramedics. However, the internal supply line has been affected by reducing numbers of staff who meet the University entrance criteria, so significant work has been done with HENW to develop and support pre-diploma programmes to ensure the continuation of this supply line. We had negotiated an improved position with HENW of 240 commissions which are vital to our paramedic supply line and will assist us in meeting to needs of the Urgent and Emergency Care Review. Unfortunately, the Comprehensive Spending review and the impact on HEE have led to a delay in confirmation of commissions for Confirmation has now been received of commissions for 240 places in but the delay means that we will not be in a position for the proposed spring cohort of direct entry students which will affect outputs in Objectives and Innovation Organisational Development Directorate Goal Objective Planned Outcome Contribute to organisational redesign processes and resourcing for the organisation the right numbers of high quality staff to deliver changing models of care, increased efficiency of services to meet financial challenges and drive culture change to improve quality To ensure staff are healthy, well and at work. To deliver an improvement in Paramedic vacancy position across areas To provide effective HR support to PTS mobilisation To improve staff Health and Well Being and motivational measures, including attendance Overall reduction in vacancy gap Improvement in hard to recruit areas - Manchester & North Cumbria Continued development of future supply line Retention strategy Workforce and mobilisation plan Effective management of TUPE arrangements Deliver H&WB action plan Deliver V&A action plan Embed AIT practice & extend scope of work Improved attendance levels Staff survey outcomes for engagement/motivation improve Deliver H&WB CQUIN schemes 18

19 Directorate Goal Objective Planned Outcome High performing, competent, safe, quality workforce able to do the job and displaying the right values and behaviours Enabling our managers to create positive environments which support and motivate staff to work in culturally competent ways. This will be achieved through the development of a diverse range of leadership styles, skills, values and behaviours. To evaluate implementation options for the new ambulance apprenticeship qualification Design and develop an essential learning programme for managers across the Trust Programme ready to deliver & approval of business case Secure external funding streams mapping of new role & evaluation of impact on service delivery model Induction programme leadership development programme Revised performance management framework Develop best practice in promoting Equality & Diversity throughout the workforce and develop the capability of staff and managers to respond appropriately to diversity issues related to workforce and patient experience. To deliver improved EDS assessment against workforce goals Improvements to resources & training Improved workforce diversity Positive action programmes in place Apprenticeships implemented 11. Approach to Financial Planning The past year has been a difficult financial year for the Trust. This started with the mediation process to agree the contracts, which led to significant investment in frontline resources. However despite this for the first time since the Trust was established in 2006/07 the Trust had a starting position of a planned deficit. This deficit was due to a number of contributory factors including: 111, PTS old contract and increased CIP target. The key points to note are: The Trust is planning a break even position for 2016/17 The TDA set the Trust a control for 2016/17 There is a significant cost improvement requirement There is a significant capital expenditure requirement The underlying financial position of the Trust remains strong with a rating of 4 on the liquidity ratio score, with an overall continuity of service risk rating of 4. The Trust has a strong closing cash position Efficiency saving for 2016/17 19

20 For 2016/17 the Trust has a programme of 26 schemes which will go towards the delivery the CIP target. All the schemes will have a Quality Impact Assessment. As described in the approach to Quality planning, this process includes an independent review by the Director of Quality (Nurse Director) and the Medical Director in addition to further reviews by the Executive Management Team, through the Cost Improvement Programme Steering Group, and the Quality Committee and the Finance Investment and Planning Committee, allowing the Trust the opportunity to triangulate the financial efficiencies with potential impact and risks relating quality and workforce. Capital The Trust is planning a Capital Programme in 2016/17 with which covers three core areas namely vehicles, estate and IM&T. The Trust is not envisaging the need for borrowing/pfi or alternative sources of finance. In 2015/16 the Trust disposed of 5 sites and for 2016/17 it is planning on disposing of further sites Lord Carter s provider productivity work programme Workforce- Tight management of annual leave, sickness and use of appropriate training can account for differences of up to 4% in productive time, according to Lord Carter report and these are areas that the Trust is focussing on. Estates Management The Trust continues to look at replacing old inefficient estate with modern alternative co-locating with fire and police where appropriate. Also continuing to improve energy efficiency and reduce carbon emissions associated with vehicles and estate. For example there is the roll out of solar panels and improved lighting to stations where it has been assessed that savings can be made. More productive services dealing with patients outside of A&E department The Ambulance service is suitably placed to assist in the reduction of unnecessary A&E attendance. NWAS is working with commissioners to further develop schemes such as community paramedics, Urgent Care Desk and Falls teams to increase Hear and Treat and See and Treat rather than conveying to A&E Departments. Greater efficiency through reduction of waste and improved supplier contracts - Procurement The Trust continues to work on national specifications and contract where possible to obtain the best procurement outcomes, good examples of this are the fuel contract and the 20

21 national uniforms group. In 2016/17 we will continue to review contracts and drive down prices, collaborating with other Trust and emergency services to provide the best value for money for the tax payer. Agency The amount of agency has been minimal for NWAS as we do not use agency for paramedic posts. The Trust recently mobilised the 111 contract which currently relies on agency and will continue to do so in the early part of the five year contract. The Trust has plans in place to increase recruitment and reduce the level of agency required to deliver the service and this will be a focus of attention in 2016/17. Elements of the call centre for the Patient Transport Service have been using agency as the Trust waited for the outcome of the contract tender. Now the outcome is known and NWAS has been successfully awarded the contracts for Cumbria, Lancashire, Mersey and Greater Manchester from 1 st July 2016, the recruitment has commenced with the aim of reducing agency usage post mobilisation. Risks The major financial risks are known and detailed in the Trust risk register. (The risk register includes full mitigation details). 12. Objectives and Innovation Finance The finance Directorate has developed a set of objectives for 2016/17 that will support the achievement of all the national standards and contract requirements. 13. Links to Emerging Sustainability and Transformation Plan (STP) NWAS covers the whole of the North West and it is envisaged that the organisation will be involved in multiple STPs. The configuration and footprint for the STPs for the North West has been agreed. These are as follows: North Cumbria aligned to the Success Regime South Cumbria and Lancashire Greater Manchester aligned to the GM Devolution Cheshire and Mersey at a recent workshop commissioners collectively decided to support a single STP on a Cheshire & Merseyside footprint In Greater Manchester and North Cumbria the development of the strategic plans for Devolution and the Success regime respectively will form the basis for the STP. The 21

22 arrangements in South Cumbria and Lancashire and Cheshire and Mersey are still nascency with providers and commissioners due to meet in the coming weeks. NWAS is working with our Co-ordinating Commissioners at Blackpool CCG to ensure the local systems are fully aware and actively engage the ambulance service in the development of their local health and social care plans. As described in the STP letter dated 16 th February (Gateway reference: 04820) further discussion will be required in working through the implications when planning for ambulance services and, for areas within a proposed devolution footprint that cross STP boundaries. Where appropriate we will contribute to the identification of the three gaps and key priorities to address each of them. The Trust will endeavour to reflect the priorities of the local STPs however it has been noted that this will be challenging for the organisation, with potentially conflicting priorities from the different STPs. 22