Annual Plan Document for 2016/17. Black Country Partnership NHS Foundation Trust

Transcription

1 Annual Plan Document for 2016/17 Black Country Partnership NHS Foundation Trust

2 Annual Plan for y/e 31 March 2017 This document compiled by (and Monitor queries to be directed to): Contact One Name Kuli Kaur-Wilson Job Title Head of Transformation Programme Management Office address Tel. no. for contact Date 1 st June 2016 Contact Two Name Angus Hughes Job Title Deputy Director of Finance address Angus.Hughes@bcpft.nhs.uk Tel. no. for contact Date 1 st June 2016 Approved on behalf of the Board of Directors by: Name Joanne Newton (Chair) Approved on behalf of the Board of Directors by: Name Karen Dowman (Chief Executive) 2

3 1.0 Introduction This plan describes and triangulates Black Country Partnership NHS Foundation Trust s (BCPFT s) short term quality, workforce and financial objectives over the coming year. The plan has focused on the delivery of high quality specialist learning disabilities, mental health and children s services during an unprecedented period of challenge for health and care services nationally. It has been developed in the context of a recent Care Quality Commission (CQC) inspection combined with significant sustainability challenges for the Trust. In response the Trust has led and been engaged in a number of partnerships across the local health economy to enable transformational change to be delivered at pace so that services can be protected and improved for the vulnerable people in our communities. 2.0 Context The Trust is proud of the reputation it has for delivering high quality services and wants to ensure that this is maintained into the future. Recent recognition has been received for its Health Visiting Service described as the best in the West Midlands by NHS England; high quality cost effective models of care for street triage and the Oak unit liaison service based at Sandwell Hospital; the engagement with Learning Disability service users to improve health provision across the Black Country; and the reputation earned by the therapeutic paediatric services with the users, families and carers of the service. At the end of November 2015 inspectors from the Care Quality Commission assessed whether Trust services were safe, caring, effective, well led and responsive, and assigned an overall rating of requires improvement. Whilst this was disappointing there were a number of positive outcomes including: Community based mental health services for older people which were rated as Outstanding For Caring we were rated as Good overall, with our Children Young People and Families community services rated as Outstanding For Responsive we were rated as Good overall. All our inpatient wards were rated Good All of our Learning Disability services were rated Good Staff opinion surveys have demonstrated improvements in some areas (e.g. appraisal uptake and staff motivation at work), however considerable work is still needed to change staff perceptions and to boost satisfaction in a number of areas, and this is of paramount importance to the Trust as it recognises that during a time of considerable change, the ongoing delivery of high quality services is reliant on a well-developed and committed workforce. The strategic planning submission in 2014 to Monitor highlighted the significant financial challenge over the next five years. Historically the Trust has had an excellent track record of achieving the expected 4% cost improvement targets (CIPs), however, the Board identified that a continued high level of CIP delivery could risk service quality given the pressure from too high a proportion of non-recurrent schemes combined with the pressures from continued cost savings and under-investment in core services. In addition to this the investment required to mitigate risks around infrastructure and safer staffing levels has been acknowledged to require transformational change to deliver the scale of savings required. In response to the sustainability challenge the Trust undertook a detailed options appraisal exercise to determine a long term strategy. This determined that a partnership with services that offered similar and complementary services in a close geographical region offered the 3

4 best opportunity to sustain and improve services for the people that the Trust served, by enhancing the range of services, improving choice and making the most efficient use of resources. Following a thorough assessment process centred around culture and values, the Trust announced in December 2015 that the sustainability partners would be Birmingham Community Healthcare NHS Foundation Trust and Dudley & Walsall Mental Health Partnership NHS Trust. This solution has been widely supported by Trust Governors, Commissioners and Staff as the best fit to ensure that our patients, carers, families and communities are provided with the best quality services in the future. During 2016/17 the Trust will seek to review and progress the potential benefits achievable through this exciting partnership, called Transforming Care Together, in line with the vision of improving services across Birmingham and the Black Country. The Transforming Care Together programme is a pro-active forward-looking programme that will address the long term sustainability risks and deliver benefits for all the Birmingham and Black Country populations. The partnership is already identifying opportunities for efficiencies through joint working and shared posts and will continue to do so during 2016/17. This combined with the grip and control overseen by the Turnaround and Investment Committees allows the Board to declare a position of sustainability for the period 2016/17. Nationally there continues to be a greater focus on Mental Health (including through the publication of the Five Year Forward View for Mental Health), with recognition of the years of underfunding and sparsity of resources to deliver care and support in line with the actual scale of need. This in turn has had a direct impact on local commissioning strategies and interest in Trust services, with the added challenge of balancing parity of esteem with budget cuts across the public sector, and particularly social care. The Trust s main commissioners have identified a number of strategic priorities, all of which inform our development plans for 2016/17. The Trust is an active partner in a range of strategic transformational programmes and partnerships including three Five Year Forward View Vanguards in our region. The most significant of those is as a main contributor to the Mental Health Alliance for Excellence, Resilience, Innovation and Training (MERIT) with our partners Birmingham & Solihull Mental Health NHS FT (BSMHFT), Coventry & Warwickshire Partnership NHS Trust (CWPT) and Dudley and Walsall Mental Health NHS Trust (DWMH) to deliver benefits to Adult Mental Health service users, particularly on three key clinical work streams of Crisis Care, and Recovery. Key development plans are overseen through a Programme Management Office (PMO) governance approach to oversee the strategic alignments and prioritisation of key priorities, embed standard systems and processes, provide expert support to the delivery of change, and oversee the allocation of project resource in line with strategic priorities. 2016/17 plans are designed and delivered through a trilateral approach 4

5 between the clinical groups, Transformation/PMO and finance, and are aligned to both the developing clinical strategy and the cost improvement programme. This approach ensures that the most expert project/change resource is ring-fenced for the most transformational work to increase the likelihood of successful delivery against projected outcomes. In early 2016 the Trust acknowledged a change in approach to the development of CIP s, with targets being set to achieve a service contribution rate (identified as 27% for operational groups). To facilitate this new service contribution approach to setting CIP targets, budgetary reporting information for 2016/17 will be presented to show the full picture of income, expenditure and contribution. Groups and their Service Line Management (SLM) teams will also be provided with more sophisticated data to enable them to scrutinise overall performance in an effective manner. The Trust recognises that the achievement of targets will only be met if there is positive sign up to schemes from the leadership team with large scale transformation being led jointly by operational, clinical and PMO leads. Recognising that many, easily achievable cost improvement schemes have already been delivered, some of the new schemes moving into 2016/17 relate to the delivery of a one clinical service model across the current portfolio of services and simplifying models of care, with other schemes being generated based on areas where services are out of alignment with benchmarking data e.g. as related to the skill mix of teams or working practices/productivity and utilising (where relevant to our services) recommendations of the Carter Review Operational productivity and performance in English NHS Acute Hospital: unwarranted variations (Feb 2016). Overall development plans for 2016/17 can be summarised as follows; 5

6 3.0 Approach to Activity Planning The following summarises the Trust s 2015/16 out-turn and draft activity plan for 2016/17: Adult Mental Health 2015/ / /17 Plan FOT Plan Inpatient Bed days 34,717 34,152 34,152 Community & Outpatients Contacts 129, , ,629 Older Adult Inpatient Bed days 17,895 17,272 17,272 Community & Outpatients Contacts 44,322 44,624 44,562 LD Learning Disabilities 2015/ / /17 Plan FOT Plan Inpatient Bed days 19,174 17,403 20,498 Community & Outpatients Contacts 33,043 31,431 32,182 CYPF Children, Young People & Families 2015/ / /17 Plan FOT Plan Community Contacts 81,016 88,387 88,387 CAMHS Community & Outpatients Contacts 30,285 29,811 29,825 Forecast outturn activity for 2015/16 adult community contacts was lower than planned as a result of social worker activity being included in the plan but no longer being recorded as part of Trust activity. 2015/16 out-turn has formed the basis for 2016/17 plans, with the exception of LD inpatients where occupancy is projected at 85.6% compared to 63.1% in 2015/16. The Trust continued to be a member of the NHS Benchmarking Network during 2015/16 and participated in a number of benchmarking projects, the results of which have been shared with the local MERIT vanguards to inform future developments. Historically contracts with main commissioners have been set on a block basis, with activity reported for information and annual plans set on forecast outturn adjusted to reflect any agreed service changes. The Trust has below the national average benchmark number of Mental Health beds (Adult and Older People) placing greater emphasis on the need to balance capacity and demand, despite it being particularly difficult to predict peaks and troughs in demand with admission not following the recognised patterns seen in physical acute beds. Of particular note regarding in-patient services for 2016/17: The Trust is planning to reduce its number of Learning Disability Assessment and Treatment beds. This has been planned in conjunction with commissioners clearly identifying how the needs of people with learning disabilities will be met in the community as part of the change. The Trust has aimed to move to cost and volume contracts with its commissioners in 2016/17. This will allow the more effective use of beds to meet changes in demand and resolve quality issues. The Trusts Acute beds have a high turnover, requiring a balance between financially optimum occupancy and an availability of empty beds for emergency admissions. Significant focus is given to the patient s pathway ensuring their length of stay is managed and robust discharge planning is in place to support this. 6

7 The Trusts Specialist beds have a slower turnover, with a potential waiting list and aim for 100% occupancy. In line with this the Trust employs a marketing strategy to ensure commissioners are aware of the current bed state and any upcoming discharges. With regards to Community Services: Contacts have a direct correlation with the workforce capacity; activity mapping is undertaken as part of each contracting round focussing on services which are: newly developed; have undergone changes in working practice; or services where activity performance is not within the agreed tolerances. During 2015/16 the Trust has reviewed its data definitions and issued local guidance to ensure that all non-face to face activity which supports direct patient care (e.g. telephone activity, contacts with carers and training) is recorded consistently across the Trust. This in turn informed our 2016/17 contracting negotiations particularly as this activity is increasing as new models of care develop. The Trust plans to develop its approach to recording other indirect patient contacts/events (e.g. liaising with other healthcare workers and training/development) during 2016/17. The Trust is looking to move towards cost and volume community contracts by 2017/ /17 will be used to develop capacity plans against developing service models, ensure that activity is robustly collected and that appropriate Time to Care projects are delivered to ensure the workforce can maximise its patient related activity. The Trust continues to report monthly to commissioners against patients in the organic/dementia mental health care clusters. Commissioners have also monitored the Trust s mental health access targets as part of local quality reporting requirements during 2015/16. The Trust has consistently met both IAPT targets (75% treated within 6 weeks and 95% treated within 18 weeks) for both main commissioners throughout the year. Meeting the target of more than 50% of people experiencing a first episode of psychosis will be treated with a NICE approved care package within two weeks of referral has been challenging throughout 2015/16. This has been as a result of capacity issues within teams and very high DNA rates. Monthly exception reports and action plans are shared with commissioners and these will continue as we move into 2016/17. With regards to other developments, the Trust currently records activity on three different Patient Administration Systems (PAS) from which activity and performance monitoring is undertaken. Plans are in place to migrate all data into one PAS system during the early part of 2016/17 providing a more efficient single source of data. In addition, during the latter part of 2015/16, the Trust has implemented a new contract monitoring and reporting system (Service Level Agreement Monitoring, SLAM) in shadow format into which all data sources can be uploaded. During 2016/17 SLAM will be embedded as the single source of finance and activity monitoring, thus giving assurance that all activity is processed, allocated, reported and invoiced. Finally, in line with the aim of having a paperless NHS by 2020, the Trust is working towards digitising its patient records by developing a best of breed Electronic Health Records (E-HR) system internally to provide staff with tools and opportunity to deliver safe care and access clinical records at point of care. A number of key applications will be deployed as part of the implementation of the E-HR system including, Bed Management, Summary Care Records, Dashboard, e-prescribing, and e-referral (which will support the patient choice agenda). 7

8 4.0 Approach to Quality Planning 4.1 Approach to Quality Improvement Led by the Executive Director for Nursing, AHP s and Governance, in 2016/17 the Trust will build on previous work (pictured in the below extract from the Trust s Quality Strategy ) to develop a three year Clinical Strategy for services. Building on these key considerations during 2016/17 are the following developments and regulatory changes: The Trust has noted and responded to the Assurance Association of Medical Royal Colleges' guidance on Responsible Consultant to ensure that patients in hospital are aware of the key individuals who are responsible for their care as follows: Patients have a named Responsible Consultant during their hospital admission. This individual is also the Responsible Clinician for those patients detained under the Mental Health Act during their hospital admission. Patients are allocated a Named Nurse on admission to hospital. Patients and family members are supported to be clear about who the Responsible Consultant and Named Nurse are during their hospital admission The Trust has officially signed up to the campaign Sign up to Safety and developed the following pledges against which it will continue to deliver during 2016/17: 8

9 1. Putting safety first. We will Continue with the on-going work to reduce the number of medication errors by 10% over the next 3 years Reduce the numbers of reported incidents of physical violence and aggression to patients and staff by 10% over the next 3 years Move away from learning lessons once an incident has taken place and towards anticipating future risk areas. We will do this by monitoring trends and themes from complaints to identify high risk activity areas, using past harm as an indicator to drive change Clearly define what we mean by harm in line with NHS England and CQC definitions so our patients know what we re measuring and what we re aiming to reduce Publish patient safety data on our website for patients and members of the public to access. We will develop a dashboard tool to ensure information is accessible and meaningful to patients Maximise all opportunities to share improvements in safety with our patients and the public Develop and publish a 3 year Patient Safety Strategy to sit alongside the Quality Strategy concentrating on the work to be undertaken to improve patient safety outcomes 2. Continually learning. We will We have already launched our 3 year Patient Experience and Involvement Strategy which aims to ensure that people have a good patient experience and there is a continuous cycle of listening, learning and improving services Forge more robust links between complaints and incidents to improve early warning systems and areas of risk for patient safety Continue to build a culture of challenge where it is expected that staff speak up when areas of deficiency and opportunities for improvements become apparent Use information from incidents and complaints to analyse incident trends and themes to highlight continuing system weaknesses Maximise opportunities to educate patients in managing their own safety risks to reduce incidents e.g. fall risks, safely managing their medication 3. Being honest. We will Continue to foster an open and transparent culture of sharing when things go wrong Include patients and families in Root Cause Analysis (RCA) investigations as business as usual not just when required under statutory Duty of Candour. This will make the investigation a more collaborative process enabling the patient and families to answer the questions they have Improve the timeliness of information sharing and response times for findings and action plans to provide further assurance following significant incidents. This will ensure critical actions to prevent further occurrences start immediately after the incident not await high level approval increasing staff buy-in Develop a culture of support for clinicians to build skills in engaging with patients when things go wrong 4. Collaborating. We will Recruit designated Patient Safety Champions within clinical teams. These will have a presence on the clinical areas and provide the face of improving safety for patients on a daily basis. The champions will be the first port of call for patients and families, linking up with representatives outside of the Trust to share learning and best practice Include members of the Executive Team and Non-Executive Directors, as well as patients, carers and Governors in conducting PLACE assessments and other quality visits Continue to proactively engage with the CCGs in sharing organisational learning, themes and trends working in partnership with GPs, local health care providers and patient representative groups Continue to hold quarterly Quality Summits to share best practice from within the Trust and promote sharing of learning from across the organisation Continue to include patient stories in the Trust wide quarterly lessons learned bulletin to share good and bad patient experiences, fostering learning from experience 5. Being supportive. We will Continue to build a culture of challenge where it is expected that staff speak up when areas of deficiency and opportunities for improvements become apparent and they are supported to do so Introduce a See it, Report type campaign to encourage staff to report concerns. We will use Patient Safety Champions to promote this at a group level to front facing staff Strengthen routes of escalation to support staff to speak up to their leaders about their observations and concerns and be confident that action will be taken. Seeing results will improve buy-in from staff members. 9

10 Top 3 Quality Improvement priorities for 2016/17: Services Priority Why this is important The outcomes we want to achieve are Mental Health Improve the physical health of inpatients (through improved monitoring of their weight, Body Mass Index and the risk of malnutrition) Malnutrition can have a number of adverse effects on the body including breathing difficulties, increased risk of infection, difficulty staying warm, increasing the risk of hypothermia (the inability to maintain normal body temperature). The Malnutrition Universal Screening Tool (MUST) is a five-step tool used by health professionals in hospitals, or in the community, to accurately identify those who are at risk from malnutrition. The screening tool also includes guidelines for providing an effective treatment plan that is appropriate for the patient. First two quarters of 2016/17, each ward will aim to attain a minimum 90% completion rate for weekly MUST assessments, or record an appropriate rationale for non-completion The next two quarters of 2016/17, each ward will aim to attain a minimum 95% completion rate for weekly MUST assessments, or record an appropriate rationale for non-completion Learning Disabilities Children, Young People and Families (CYPF) Review the use of anti-psychotic medication in challenging behavior Listen to and learn from regular user feedback across all services The National Institute for Care and Health Excellence recommends that, antipsychotic medication should only be considered if the risk to the person or others is severe, for example violence, aggression or self-injury. The Winterbourne View Report in 2012, also raised concerns about the over use of psychotropic medicines in people with learning disabilities. Further, whether psychotropic medication is sometimes administered too soon, before identifying the root causes of the challenging behaviour. The NHS Constitution states that all healthcare providers should aspire to put patients at the heart of everything they do and actively encourage feedback from them and the public and use it to improve services. Many of the children s services are relatively new to Black Country Partnership so the need to obtain regular feedback is particularly important, to ensure they are young people friendly and help to inform and shape decision making in the future. Continue the work of embedding and improving positive behaviour support plans Train our staff to have the skills and confidence to be able to reduce challenging behaviour Justification for the choice of medication to be clearly documented Regular medication reviews taking place Discharge letters clearly identify the rationale behind prescribing Health visiting services will seek to establish a patient experience focus group with particular emphasis on supporting engagement with fathers. Gather information across all services to scope what patient experience activity they undertake to support sharing of good practice and identification of areas for improvement Ensure the views of service users are used to shape the development of CAMHS services Improving links with key external stakeholders such as Healthwatch Development of service user forums and other methods of patient engagement and feedback to help shape service delivery Utilise the results of the Friends and Family Test to inform the work identified above Children s Quality and Safety Group will receive monthly updates and monitor progress through the year 10

11 In delivering its key quality priorities the Trust is mindful of the key risks described to the right, all of which relate to its biggest asset, its workforce. The mitigation applied in response to these risks is also described. 4.2 Seven Day Services National policy to make NHS services available seven days a week poses significant deliverability and financial challenges around clinical staffing outside of traditional hours. The Trust s commitment and involvement in the Mental Health Alliance for Excellence, Resilience, Innovation and Training (MERIT) vanguard with our partners Birmingham & Solihull Mental Health NHS FT (BSMHFT), Coventry & Warwickshire Partnership NHS Trust (CWPT) and Dudley and Walsall Mental Health NHS Trust (DWMH) will over 2016/17 seek to develop a replicable clinical model for acute care seven day working including looking at the possibilities of developing shared clinical rotas, aligned HR policies and consistent consultants contracts. 4.3 Quality Impact Assessment Process The Trust has acknowledged that the delivery of cost improvements programmes (CIP s) at the level previously demonstrated and simultaneously not compromising quality and safety of services has become increasingly difficult. In order to ensure the development of meaningful programmes the responsibility for developing CIP s remains with the clinical groups who are then supported in terms of delivery and monitoring by the Trust s PMO and Finance teams. This tri-lateral approach is interdependent, iterative and time-defined. All CIP s are risk assessed against a Quality Impact Assessment (QIA) and an Equality Impact Assessment (EIA). All plans are approved through the Star Chamber (with members being Medical director, Executive Director of Nursing, AHP s and Governance, Associate Director for Quality and Governance and the Head of Equality and Diversity) to ensure that any potential adverse effects relating to safety, effectiveness, experience, equality or diversity are identified and mitigated. The Star Chamber reinforces the organisational culture of promoting and balancing the interest of patients and staff with financial and performance targets. High level risks identified are recorded as appropriate on the Trust Risk Register which is then reported monthly to Trust Board. All plans are then reviewed at six monthly intervals and then again after implementation, when they again have a QIA and EIA completed. 4.4 Triangulation of indicators The Trust has implemented systems and processes, as described in the Board Assurance Escalation Framework, to triangulate quality, activity and workforce data, facilitating the identification of trends, issues or concerns for action and/or escalation. This is demonstrated in group, committee and board minutes. Following the refresh of the Trust s strategic objectives, reporting now pulls together the board assurance framework, high level risk register and clinical quality dashboard, with plans in place to further integrate with the financial and performance report to enhance the triangulation approach. This rich source of information enables senior leaders to assess risks to the organisation in line with strategic 11

12 objectives, enabling direct action in the appropriate area to maintain the quality services provided. 5.0 Approach to workforce planning Our workforce is the key interface with service users, carers, families and the public and the quality of our staff is a key determinate of the quality of care the Trust delivers. Our continued focus is to empower our staff through effective engagement and to support them through excellent leadership, support systems and training and development. To realise this ambition the workforce strategy is the core of the Trust s goal of attracting, retaining and developing a capable and flexible workforce and then realising the elements of the quality strategy focused on clinical effectiveness. The trust has a collaborative multi-disciplinary approach to the creation of workforce plans to enable an appropriate balance between clinical, financial and operational drivers. This is achieved by ensuring that plans deliver the clinical strategy of the service and are financially viable. Accountability is jointly held by clinical, operational and corporate leaders. The Trust works closely with its local commissioners. The clinical strategy and resultant development plans being developed during 2016/17 are based on the wider local health and care system and commissioning strategy in order to meet the needs of the local population. Alongside this, the workforce plans, which are integral to all services, are developed with the preface that, where possible, the workforce is representative of the local community that we serve. Workforce plans, jointly developed by the clinical groups and Corporate Service leads, in line with the Trust governance processes, are rigorously risk assessed. Mitigating actions are identified and addressed as appropriate prior to approval. Approval is initially through the Clinical Group Management Boards, with final sign off through the Workforce Committee which is a sub-committee of both the Quality and Safety Committee, and Business and Performance Committee reporting through to the Trust Board. The Trust has in place an electronic rostering system which enables the Trust to report on safe staffing levels and is currently being developed to further this support. The overarching principles and objectives underpinning the system are to maximise the effective management of the Trusts staffing resource. It provides continuous improvement in the utilisation of existing staff and an effective use of temporary staff in order to enable a reduction in bank and agency spend, making use of best practice identified both locally and nationally across all wards and departments (both clinical and non-clinical). In utilising the e-rostering system effectively, the Trust aims to minimise its use and reliance on agency workers. The Trust is currently operating within Monitor s rules in relation to the use of framework agencies, and the agency rate caps. In order to meet the Trusts cap, the following is taking place: The Trust is aiming to maximise its use of rosters through the e-rostering system in order to ensure better utilisation of the staff we have in post. A robust authorisation process is in place for any agency requests (outside of rostered areas), allowing for executive level scrutiny and sign off for any agency requirements outside of in-patient nursing shift coverage. Work is currently underway exploring the use of a neutral vendor which will provide a consistent approach to requesting and booking agency workers and standardised rates. 12

13 The Trust requires all agency work to be registered through our electronic rostering system with the aim that all invoices can be more accurately validated reducing the risk of inaccurate charging from agencies. The Trust continues to undertake on-going recruitment to its internal bank in order to reduce the need to engage agency workers to cover shifts. As a Trust with mental health services, we are part of the Mental Health Institute LETC, and are actively involved in the workforce transformation themes. HR involvement throughout the process assures impact on workforce and appropriate alignment with education commissioning intentions are raised and met. In order to assure the Trust around quality and safety of the workforce, and in order to identify risks, the Trust produces a combined quality dashboard which incorporates quality, safety and workforce. This dashboard is reported via our Quality and Safety Committee, and Quality and Safety Groups structures. The reports are based on KPIs, and enable the organisation to identify risks, and trends in relation to the workforce. The Trust also regularly reports on specific quality and workforce issues such as safe staffing. The trust has a robust clearly articulated board assurance framework through which workforce plans are approved. This ensures appropriate assurance can be provided to the trust board that they meet the needs of the local community, commissioners, and that they are financially sustainable. The reporting structure is via Management Group Boards and then with onward escalation through the Workforce Committee and Quality and Safety Committee through to Trust Board. This ensures that appropriate visibility and impact is assessed from a quality and safety perspective as well as ensuring that due consideration is given to national priorities, new workforce initiatives and roles.. Ongoing monitoring of plans is undertaken through the relevant committees as identified above and planned within the cycles of business for the committee and via KPI dashboards, with escalation to the risk register if and when required. Trust developments, operational priorities and impact of quality initiatives have been modelled and the overall impact on workforce numbers is outlined in the following table. Analysis of Workforce Numbers Forecast Budget Establishment Establishment Y/E 2015/16 Y/E 2016/17 Consultants Junior Medical Nurses and Health Visting (incl Bank) Sci, Tech and Ther (incl Bank) Other Healthcare Non-Clinical Staff , ,015.7 The Trust has challenging savings targets for 2016/17 and has ensured that staffing reductions are focused on non-clinical staff. The Trust has implemented programs to improve recruitment and retention, provide incentives to recruit apprentices and minimise the reliance on expensive agency staffing. 13

14 Key challenges and priorities for 2016/17 include: The Trust has had a challenging year in respect of recruitment and retention of clinical staff, particularly amongst registered nursing. This is a recognised national issue and the Trust has had to explore creative solutions to this issue. Reducing sickness which continues to be high. This, along with the vacancies, results in increased bank and agency usage. To develop and embed integrated workforce systems to support and enable managers to undertake their roles and make informed decisions. The Trust continues to need to address the challenges of an ageing workforce with over 2/3rds of staff being over 40, and a 1/3 rd of these being over 50. Recruitment of both clinical and non-clinical apprentice roles, supporting the Trust to establish a workforce reflective of the community we serve. Our staff survey has again improved in some key areas, however there is still a need to continue to embed and enhance staff engagement and develop a consistent culture in which the Trust s values are truly embedded. To address these priorities will require the continued development of the right culture and leadership through the delivery of our key objectives. 14

15 6.0 Approach to financial planning 6.1 Financial forecasts and modelling /16 Outturn The 2015/16 plan identified the delivery of a financial surplus of 302k, underpinned by a number of risks as this was understood to be a challenging target. Early into the year the Board determined that it would not be possible to deliver the planned surplus, anticipating instead an operating deficit of c 1m. This change in financial forecast led to the Trust s regulator, Monitor, opening an investigation into the financial position. The investigation included a desk top review of performance as well as a meeting with representatives of the Trust Board. Monitor has received assurance of the grip and control initiatives which the Trust is adopting and have now closed their investigation. It is recognised that the Trust is unlikely to be financially sustainable in its current form in the longer term, and the Board of Directors has been through a rigorous and engaging process to determine the future sustainability of the services it provides. The 2015/16 plan highlighted that there would be expenditure associated with sustainability planning, but this was not included within the plan, as financial support for this project was being sought. Despite conducting a significant strategic review and partner selection exercise, the Trust has had no external consultancy support for this work, and has delivered a significant work programme at an incremental cost against the plan of only 110k. The Trust s audited financial position for 2015/16 gives a Financial Sustainability Risk Rating (FSRR) score of 1 which is lower than the planned Continuity of Services Risk Rating score of 3. The risk rating is lower than planned due to the deterioration in liquidity. This has been driven by an improvement in processes and control over balance sheet liabilities resulting in a net cash outflow in the period. The forecast deficit against the original planned surplus has also had an adverse impact on cash and the full year FSRR, primarily driven by the continuing high usage of agency staff, loss of income associated with temporary closures necessitated by investment in the estate, and non-delivery of cost improvement programmes brought forward from the previous year Assumptions within Operational Annual Plan 2016/17 The Trust has been set a control total of 1.1m deficit in 2016/17 as part of the overall NHS Improvement financial plan. This target deficit includes an allocation from the Sustainability and Transformation Fund of 610k, which is dependent upon achieving the plan. Based on this position, the Trust does not foresee a requirement for Department of Health (DH) interim support or planned term support for the year ending 31 March Q1 Q2 Q3 Q4 2016/17 m m m m m Operating Income Operating Expenses (24.821) (24.695) (24.424) (24.318) (98.257) Non-operating (1.033) (1.033) (1.033) (1.033) (4.132) Surplus/Deficit (0.567) (0.421) (0.123) (0.017) (1.129) Whilst the 2016/17 plan is based on current knowledge and status of existing negotiations, there are still significant risks to be mitigated within the planning assumptions: The planned income position is set at a realistic level however a reduction in the planned income could have a negative impact on the operating position, with many costs associated with the income fixed. The risk of this is minimal as there are only two contracts yet to be signed. An increase in cost and volume contracts creates additional income risk and opportunity. The CIP challenge is exacerbated by brought forward under-performance. 15

16 The affordability of the deficit is based on the outturn cash position for 2015/16, and the working capital within the Balance Sheet. Deterioration during the year in net current assets could adversely affect the Trusts ability to fund its activities internally. As no funding has been made available to support long term sustainability strategy, the Trust has had to make an assumption that the expenditure in this area will be no more than 100k. The Trust will need to secure additional funding to compensate for cost above this level. Given the cash constraints the capital plan for 2016/17 is considerably lower than previous plans have indicated. This poses a risk both to IT digitalisation and the PLACE assessment, as well as leaving no contingency or flexibility in case of unforeseen events. The information within the financial plan reported below highlights the assumptions and outputs from the Trust s one year financial model. The assumptions have been considered and assessed through the Board of Directors and its relevant sub-committees Income The following table shows the income position included in the 2016/17 financial plan, with 2015/16 figures for comparative purposes: Element 2015/16 Out Turn 000's 2016/17 Value in Plan 000's % Movement Baseline 100,464 98,152-2% Service Development 0 2,373 Revenue Generation CIP Sustainability Funding , ,260 1% As shown in the above table, income of 2.4m has been negotiated for Service Developments. The agreed or anticipated values for the main contracts by Commissioner are shown in the table below (developments and income generation are not included within this table). Contract (Contract values excluding developments and income generation) 2016/17 Value in Plan 000's % of Trusts Income 16/17 Sandwell & West Birmingham CCG 33,689 34% Wolverhampton CCG 28,559 29% Dudley CCG 11,548 12% National Commissioning Board (Gerry Simon, Liaison & Diversion & Health Visiting 2,972 3% Walsall CCG & MBC 2,497 3% Spot Purchases (Ridge Hill, Pond Lane, Newton, Penrose, Suttons, PICU, Penn) 5,290 5% Birmingham CCG 1,758 2% Dudley Public Health 4,708 5% Education & Training 1,701 2% Other Contracts (individually less than 1% of income each) 5,169 5% Various - Non Contract Activity 261 0% 98,152 16

17 The plan is based on the outcome of negotiations for 2016/17. There are two contracts yet to be signed. These have been included at the Trust s best estimate of the likely outcome of those negotiations. Key variances from 2015/16 out-turn to 2016/17 plan relate to: An overall 1.24% net inflationary uplift in income of 1.2m; o Deflation of 2.0% for CIP target of ( 2.0m); o Uplift of 3.24% for changes in National Insurance costs, annual pay award and general inflation of 3.2m; Service developments 2.4m; Reduction for non-recurring income received in 2015/16 of ( 4.2m); Impact of activity/commissioner changes 0.8m. Receipt of sustainability and transformation funding 0.6m Expenditure Given the timing of the submission of the annual plan, the unaudited accounts for 2015/16 have been used as the indicative 2015/16 out-turn. The following table reflects the expected costs in 2016/17 including the impact of inflation, known adjustments identified through budget setting, service developments and cost improvement programmes. Element 2015/16 Out Turn 000's 2016/17 Value in Plan 000's % Movement Pay (inc Agency) 78,987 80,194 2% Drugs 1,555 1,423-8% Clinical Supplies % Non-Clinical Supplies 15,646 15,376-2% Impairment of Receivables PFI % 97,952 98,257 0% The 2016/17 submission is shown as a comparison to the 2015/16 draft outturn. The key variances relate to: 2016/17 Inflation of 2.6m; Service Developments increase in expenditure of 1.9m; Non Recurrent Spend associated with Non-Recurring income ( 2.9m); Cost Improvement Programmes 2016/17 (CIP) of ( 6.4m); 2015/16 Non-Recurrent CIP achievement 2.3m; Full year effect of 2015/16 Recurrent CIP achieved ( 0.1m); Recruitment to vacancies in the year 5.7m; Difference between agency budget 2016/17 and 2015/16 out-turn ( 2.1m) Impairment of receivables ( 0.7)m; PFI 0.1m; Other non-recurrent expenditure ( 0.1m). Agency and bank pay costs are significantly lower in the 2016/17 plan when compared to the 2015/16 out-turn. This difference arises as a result of the implementation of an expenditure cap on agency staff costs, which has been set at 3,534k for the year. Given agency expenditure levels in 2015/16, and the potential impact of the Trust s strategic plans on retention, delivery of this target will be challenging. 17

18 Expenditure is based upon operational expectations for 2016/17, with 100k set aside within the plan for sustainability costs. The established partnership between ourselves, BCHC NHSFT and DWMHP NHST is progressing well and over the 2016/17 period is likely to require funding in excess of the support identified in respective plans ( 300k total) to deliver collective objectives. Initial estimates suggest that this will require support of circa 700k in excess of the 300k ring-fenced funding to enable all aspects of service transformation, corporate efficiencies, due diligence and competition compliance work to be successfully enabled. This value excludes future redundancy risk. This is an indicative target and will evolve over coming weeks; however the underlying principle of the need for material support from an external source is clear. We request that this is noted by NHS Improvement and discussed with the partnership at the earliest opportunity Inflation The national guidance indicated that inflation of 3.1% should be applied to all providers; however an efficiency factor of 2% is also to be applied leading to an overall inflator of 1.1%. When adjusted for local nuances, this results in an increase in income of 1.2m Pay inflation has been internally modelled in line with the agreed agenda for change pay award and the increase in employer s contribution to pension resulting in an increase to cost of 3.24%. This is in line with the national guidance of 3.30%. Previously Drugs, Clinical Supplies and Non-clinical Supplies inflation rate has been included based upon all services RPI annual rate. For this version of the model, no inflation has been applied. RPI is currently at 1% for 15/16, CPI 0% Non-operating items - Depreciation and PDC Dividend The full year deprecation charge for 2016/17 is planned at 2,052k, an increase of 145k from the forecast 2015/16 annual charge. This is due to the increased asset values arising from the capital spend, but also takes into consideration the phasing of those additions during the year. Q1 Q2 Q3 Q4 2016/17 m m m m m Depreciation (0.513) (0.513) (0.513) (0.513) (2.052) PDC (0.395) (0.395) (0.395) (0.395) (1.580) Finance Costs (0.125) (0.125) (0.125) (0.125) (0.500) (1.033) (1.033) (1.033) (1.033) (4.132) The PDC dividend has been estimated on the basis of the average net asset values at 31st March 2016 and 31st March 2017 with a deduction made for the average cash balance over the financial year. The plan reflects a decrease of 45k to 1,580k in 2016/17. However, revaluation of Estate at year end and fluctuations in cash balances through the year will impact this cost Capital Expenditure The table below shows the Capital Expenditure plan for 2016/17 analysed across the main schemes. The capital plan of 2.1m has been recommended to the Board of Directors. The previously submitted five year plan included capital expenditure of 6m. The reduction has been considered by the Board of Directors in terms of risks and impact on future year capital requirements. The focus of the estate expenditure will be based on clinical need and priorities as well as in remedying significant and high defects associated with the physical condition, fire and statutory standards of the estate. 18

19 2016/17 Plan 000's 2016/17 Plan 000's Implementation Strategy - IM&T 207 IT Development Staff 400 Better Services Better Care - Essential 500 Better Services Better Care - Other 250 Equipment 100 Other Estates Schemes 443 Schemes Supported by 1516 funding 200 Total 2,100 The plan does not include provision for impairment of assets during the financial year. Upon reviewing historic trends it is common for an adjustment to be made at year end however the value of the adjustment fluctuates each year in conjunction with the type of capital work being undertaken and the impact on the current use value as opposed to market value. Current plans do not assume the disposal of any assets over the twelve month period with additions being 2,100k over the year, offset by depreciation of 2,052k leading to a net increase of 48k before impairment or revaluation. This results in the following fixed asset values being anticipated on the Statement of Financial Position (SoFP): 2016/17 Plan 000's Q1 000's Q2 000's Q3 000's Q4 000's Fixed Asset Value 66,510 66,524 66,435 66,345 The profile of expenditure is in line with the anticipated scheme delivery dates Cash Balances The reduction in the cash balance over the twelve month period reflects the forecast deficit, anticipated movements in working capital and capital expenditure (capital expenditure is largely offset by the full year depreciation charge). 2015/ /17 Plan 000's Q4 000's Q1 000's Q2 000's Q3 000's Q4 000's Cash Balances 2,206 1, The cash balance does not include any increase in loans, and it is assumed that any further funding requirements would need to be approved to support business cases as they arose. The 2015/16 out-turn cash position is 4.3m below plan for that period. This is attributable to the 1.2m full year downturn in financial performance (including non-cash items, but excluding net asset impairments), the settlement of c. 2m of prior year Community Health Partnership (CHP) invoices for property rental, additional capitalised EHR costs of c. 0.5m and other timing assumptions relating to payables and receivables Financial Sustainability Risk Rating (FSRR) The FSRR risk rating for the Trust is expected to be at 2 by the end of 2016/17. The implications of this could be increased scrutiny by Monitor of the Trust s financial performance, planning and sustainability initiatives. However, the Trust has been working closely with Monitor over the last few months and been able to provide assurance over the initiatives being taken. 19

20 2016/17 Plan Q1 Q2 Q3 Q4 Capital Service Capacity Liquidity I&E Margin Variance in I&E Margin FSRR Efficiency savings for 2016/17 The summarised CIP position included within the financial model is shown in the table below and a more detailed breakdown of the 2016/17 programme is shown in Appendix /17 Plan 000's Recurrent 2,669 Non-Recurrent 3,726 6,395 Expenditure CIP as % of Operating Expenditure (excl PFI) 6.5% % Recurrent 42% % Non-Recurrent 58% It is important to note that the above plans do not include 366k savings that have already been taken out of start point budgets. The Recurrent/Non-Recurrent split shown in the above table is reflective of the phasing of the larger clinical transformation plans. It is envisaged that savings from these schemes will not materialise until later in the financial year, so the CIP financial gap will need to be bridged on a non-recurrent basis. The FT, however, will continue to identify opportunities to improve this split throughout 2016/ Capital Planning Requirement for capital investment in estate and IT There are significant improvements in progress to both enhance the basics of the IT infrastructure and to deliver new and innovative solutions to support service delivery. This has been predominately financed within the 2015/16 capital plan, with a smaller portion being carried forward into the 2016/17 capital plan. The condition of some Trust estate is poor and investment is needed to both bring it up to a good standard for service users, and to deliver some of the planned service developments. However investment in new or significantly altered facilities would impact negatively on the Trust s financial position until such services were established and generating revenue. Capital spend on Trust estate needs to be balanced between financial sustainability and the risk of adversely impacting service delivery. The Trust s strategic sustainability partnership may positively affect the estate and IT strategies and as this is in the preliminary stages potential opportunities arising from the partnership are not included within this submission Capital Programme The Trust has made a number of improvements to control capital expenditure, maximise working capital and improve financial reporting, and will continue to embed these changes to minimise waste and create a stable platform from which the Trust can assess its sustainability as it moves forward. All capital spend requests are thoroughly challenged and assessed against the Trust s financial sustainability requirements and 20

21 the ability to deliver a quality service. All risks identified with the estate are clearly defined with clear mitigation plans assigned to each one. The Trust has had considerable capital investment over recent years in remedying significant and high defects associated with the physical condition, fire and statutory standards of the estate. The PLACE assessments in 2015/16 showed improvement over previous years reflecting the quality benefit of this investment. The Board approved a clinically led Estate Strategy in May 2015 which incorporated the findings of a sevenfacet appraisal of the Trust owned estate (entitled Where are we now? ) and this Estate Strategy is informing the capital plans for 2016/17 and beyond. A Board approved IT Strategy is now being implemented. Significant capital spend has been incurred in 2015/16. There is a further smaller capital plan included in 2016/17 to complete the full infrastructure implementation. This will create a stable environment from which to continue developments. These include additional electronic storage incorporating Disaster Recovery for the Trust, which will replace the existing Storage Area Network (SAN) and Virtual Desktop technologies to strengthen the platform for Agile Working across the Trust. The Trust will use the virtual desktop infrastructure to continue its Windows 7 rollout and will extend the pilot implementation of Voice over Internet Protocol (VoIP). Information Communication & Technology (ICT) has been identified as a key enabler to achievement of one of the Trust s strategic objectives to provide safe, effective, caring, responsive and well led services for service users. To support this work, the Trust is working towards digitising its patient records by developing a best of breed E-HR system internally, and implementing agile working to provide staff with opportunity to deliver care and access clinical records closer to patients. There may be opportunities to market this solution across other providers, which are currently being developed. Subsequently, the Trust is also in the process of upgrading its IT infrastructure, implementing a new IT Strategy to support its ambition and to continue to provide adequate care for service users. 21

22 7.0 Alignment to local emerging Sustainability and Transformation Plan (STP) The Trust is part of the Black Country Sustainability and Transformation Plan (STP) which will collaborate to develop a joint strategic plan for submission to Monitor by June 2016 covering the period to March The Black Country STP has agreed some principles to ensure that this group supports delivery of individual organisational strategies as well as the over-arching group aims: 1. The process will build on the existing local partnerships in each area incorporating that work e.g. Right Care Right Here programme and many other programmes. 2. Additional work may be required to deliver the triple aim quality, finance and true sustainability across the system, particularly avoiding moving costs around the system but delivering true efficiencies. 3. The STP boundaries will not compromise critically important relationships or patient flows across other boundaries in Staffordshire, Wyre Forest and Birmingham for example, recognising the need to work across STP boundaries where required. In line with the guiding principle of supporting individual organisational strategies the Trust anticipates that the Transforming Care Together partnership between our Trust, Birmingham Community Healthcare NHS Foundation Trust and Dudley & Walsall Mental Health Partnership NHS Trust will shape the STP for Mental Health and Learning Disabilities working closely with the lead CCG in these areas (Wolverhampton). Delivering services in partnership across a larger population size affords opportunities for enhanced specialist services, which could deliver various service improvements e.g: Enhanced support for children with serious mental health needs which currently sees them sent hundreds of miles away for specialist care; Better support to mothers and babies; Improved response for people with eating disorders; and Opportunities to better support those with personality disorders Collectively the Transforming Care Together partnership can bring together a wide network of voices to shape services across the region, and opportunities for efficiencies through agreed representation for the Partnership: 22

23 The STPs, combined with the NHS vanguards, will drive forward the new models of care described in the Five Year Forward View. The Trust is an active member in three new Vanguards. This offers potential solutions for long term sustainability of the health and care economy, but also additional complexity for organisations particularly in relation to governance arrangements. The Trust has a desire to deliver sustainable health economy solutions, but a requirement to achieve regulatory organisational requirements, which may not always be aligned. In addition to this the risk to short-term financial stability is significant given the likely level of resources required to deliver successful and meaningful transformation, during a period of national financial challenge; in addition there will be legislative challenges from competition risk that could affect the desired pace of delivery for some of these changes and the impact of instability for the health economy as a whole. 23

24 8.0 Membership and Elections In May 2015 elections were held to fill governor vacancies across both public and staff constituencies. All public vacancies were filled and there were no nominations for staff governors. Further vacancies have arisen following resignations and elections are currently in progress for both staff and public governor positions, with results due on 13 May To encourage members to stand as governors, promotional campaigns are carried out using the Trust s communications channels and events. The Trust uses an online training needs analysis tool, the output from which informs the training and development plan for governors. Governors have the opportunity to attend relevant training and network sessions as well as the opportunity to refresh their annual induction training. Constituency events were held for public members and prospective members to meet their respective governors. The annual membership event was held in the Dudley constituency in September Governors regularly attend community events to recruit new members. Governors are supported to communicate with their members via the Governor corner of the quarterly Trust newsletter Grapevine. The Trust s membership development strategy, developed with governors in April 2015 acknowledges that the Trust has a broad base of membership with pockets of underrepresentation, specifically children and young people under 16. Over the next 12 months efforts will be concentrated on both growing numbers and retaining a strong and engaged membership that is actively involved with the Trust. Specific priorities will be: More targeted engagement through collecting information on members interests to involve them more closely in Trust work; Improving the frequency of communications and introducing new channels for contact; Involving members in small interest groups and in consultations about service developments. 24