Operational Plan The Hillingdon Hospitals NHS Foundation Trust. Iss 1.0 submission to NHSI for Publication

Transcription

1 Operational Plan The Hillingdon Hospitals NHS Foundation Trust Iss 1.0 submission to NHSI for Publication

2 Table of Contents 1 Signature Page Changes from the Draft Annual Plan, which was submitted on 8 th February Approach to Activity Planning Collaboration with North West London CCGs Assessment of activity in FY16/ Priority Areas Approach to Quality Planning Approach to Quality Improvement... 7 Our 6 Quality Aims : Seven Day Services Quality Impact Assessment Process Triangulation of Indicators Approach to Workforce Planning Approach to workforce planning with clinical engagement Governance process of board approval of workforce plans Link to clinical strategies and commissioning strategies Local workforce transformation programmes and productivity schemes Effective use of e-rostering and reduction in agency staffing Alignment with HENWL Triangulation of quality and safety metrics with workforce indicators Application and monitoring of QIAs for all workforce CIPs Workforce initiatives as part of the 5 year forward view Balancing agency rules with achievement of appropriate staffing levels Systems to regularly review and address workforce risk areas Approach to Financial Planning Financial Forecasts and Modelling Efficiency Savings for 2016/ Capital Planning Link to the Emerging Sustainability and Transformation Plan Membership and Elections Planned governor elections Engagement between governors, members and the public Membership strategy THHFT Operational Plan FY16-17 Publication iss1.0 (signed)

3 1 Signature Page This document completed by (and Monitor queries to be directed to): Name David Searle Job Title Director of Strategy and Business Development address Tel. no. for contact Date 15/04/2016 The attached Operational Plan is intended to reflect the Trust s business plan over the next year. Information included herein should accurately reflect the strategic and operational plans agreed by the Trust Board. In signing below, the Trust is confirming that: The Operational Plan is an accurate reflection of the current shared vision of the Trust Board having had regard to the views of the Council of Governors and is underpinned by the strategic plan; The Operational Plan has been subject to at least the same level of Trust Board scrutiny as any of the Trust s other internal business and strategy plans; The Operational Plan is consistent with the Trust s internal operational plans and provides a comprehensive overview of all key factors relevant to the delivery of these plans; and All plans discussed and any numbers quoted in the Operational Plan directly relate to the Trust s financial template submission. Approved on behalf of the Board of Directors by: Name (Chair) Richard Sumray Signature THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 1

4 Approved on behalf of the Board of Directors by: Name (Chief Executive) Shane DeGaris Signature Approved on behalf of the Board of Directors by: Name (Finance Director) Matthew Tattersall Signature THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 2

5 2 Changes from the Draft Annual Plan, which was submitted on 8 th February. Section 3 - Further detail on Activity Planning priorities is presented in text-boxes to highlight strategy and work in progress. Though, it should be clear there is no change to the strategic priorities, themselves. Section 4 Updated following production of our revised Quality and Safety Improvement Strategy Section Approach to Quality Improvement has been updated alongside production of the Trust s Quality Improvement Strategy. Section Further detail provided about progress implementing 7 day service standards. Section Financial Forecasts and modelling have been changed following negotiations with Hillingdon CCG and discussions with Monitor and NHS Improvement. Section 7 - Revised in light of further information about the Sustainability and Transformation Planning Process. Section 8.2 Updated with further details about how we engage Governors in planning. THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 3

6 3 Approach to Activity Planning 3.1 Collaboration with North West London CCGs Unplanned growth in demand for care in a hospital setting has been a challenge to respond to in a safe and affordable way. We will work in collaboration with our commissioners to develop accurate demand and capacity plans that both fulfil the planning requirements and ensure patients have access to safe and sustainable services. Activity plans for 16/17 are informed by demand and capacity planning across North West London, which is undertaken as part of Shaping a Healthier Future (SaHF). This strategic planning programme is reshaping health and care services across the same geography from January 2012 April Trust capacity has been reviewed in terms of beds, outpatient services, cancer services, diagnostics and theatre capacity. Currently, there is insufficient capacity to meet expected demand for both A&E and diagnostic services (CT, MRI and ultrasound). In A&E, cubicle capacity remains particularly constrained, at 30% below the required number of cubicles for our expected level of activity. Hillingdon CCG commissioned an independent review of pathways through A&E. The work seeks to identify performance-improvement opportunities within the current estate. The Trust is in the process of agreeing an action plan resulting from this, to be implemented in 2016/17. In the medium term, additional capital investment is planned to increase capacity in A&E, theatres, maternity and ITU. There is increased confidence in our ability to work with commissioners to deliver their 16/17 QIPP targets. A number of schemes are underway and progress is being made towards creating an Accountable Care Partnership (ACP), which will provide a whole- systems solution for people aged over 65 years, with one or more long term condition, in North Hillingdon. The Trust has an open and collaborative working relationship with CCGs across North West London which will be strengthened by using joint open book activity planning on Unify. To facilitate this system-wide approach, the Trust is building internal capacity to incorporate demand and capacity modelling as the basis of activity planning. Representatives from the Trust s finance, informatics and business development teams attended NHSE workshops. The Trust s activity planning has fully incorporated growth, commissioner QIPP, and reconfiguration assumptions agreed with North West London CCGs as part of SaHF. The trajectory of A&E activity 2016/17 has been agreed with commissioners. This should ensure alignment with commissioners, providers and the STP process. Refer to section 4, below, for further commentary. THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 4

7 3.2 Assessment of activity in FY16/17 From April January 2016, the Trust experienced an increase in non-elective attendance of 1.7% and a 20.6% increase in blue light activity. Despite this increased demand, there has been a decrease of 9.6% of medical emergency admissions. This is due to the success of the Ambulatory clinic on the Acute Medical Unit (AMU); which has seen a 69% increase in activity over the same period. Performance against the 95% A&E standard remains a challenge, which is hindered by factors including limited number of cubicles, a high turnover in staff, and delays in discharge in downstream wards. The level of acuity treated has risen as a result of greater comorbidities presented, which necessitate longer lengths of stay. The need for capital investment to increase capacity in A&E is recognised by SaHF. However, existing capacity constraints will remain throughout FY 16/17, with partial mitigation planned in development of the Trust s new Clinical Decision Unit (CDU, more detail in text box below). Consequently, attention will continue to be focused on managing demand by adopting a whole systems integrated model of care. System redesign and patient flow within the UCC/A&E and ambulatory pathways will also improve performance and create a better experience for our patients. Improving Discharge Planning Effective discharge planning improves patient experience, reduces length of stay, and prevents re-admissions. It determines performance against a number of key indicators, including the 95% A&E standard. To address discharge planning, the Trust adopts a whole systems approach. This involves working across organisations to ensure patients are directed to the right destination and that appropriate care is delivered efficiently. The following initiatives, which improve the discharge process, will continue to be progressed in FY16/17: Internally, the Trust is strengthening discharge processes and streamlining patient pathways to remove any delays and reduce length of stay for patients. Discharge is coordinated with rapid response assistance to prevent re-admissions. Externally, working with local partners, to provide sufficient and appropriate capacity for patients who require a level of care which is between hospital inpatient services and being discharged to community and residential settings. An integrated discharge team was established in January 2016, with representation from the Trust and other NHS providers, local authority and the third sector. The team develops pathways for step down care, rehabilitation, and early supported discharge. Investments by the Better Care Fund, and initiatives like Home-Safe, an early supported discharge scheme, have delivered a 3.5% reduction in emergency care use for people aged THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 5

8 over 65 years. In addition, pathways have been redesigned to improve flow through the hospital. This work remains a priority focus in FY16/17. As part of winter system resilience planning, social care coordinators started working on hospital wards in January This is supported by Patients know Best an innovative company which integrates health and care databases and develops patient-facing portals. Demand & Capacity Modelling to Improve A&E Performance Type 1 activity continued to increase throughout the year putting unprecedented demand on unscheduled care services. Consequently the Trust was unable to maintain the A&E four hour standard. Sustainable A&E performance and high-quality unscheduled care is one of our priority goals for 2016/17. To achieve this, the Trust has been working extensively with Hillingdon CCG, to develop a comprehensive recovery and improvement plan to strengthen unscheduled care performance. The improvement plan included an independent review of A&E flows and pathways. This 3-phase programme focused on attendance prevention, improving flows and capacity within A&E and onward referral into the hospital. By implementing the plan the Trust is predicting that it will be able to consistently achieve 95% against the four hour standard. Achievement against this standard is not without risk and is predicated on activity growth of no more than 2.5% and having an expanded A&E department by December The Trust also remains concerned about the significant increase in blue light activity which has increased by 53% in two years. This has put considerable strain on the Trusts 4 bedded resuscitation unit. Further growth in this area will significantly compromise the Trust s ability to meet the 4 hour standard. Winter 15/16 has been difficult and in the latter months activity has increased by 10%. This could impact on Q1 delivery if activity does not return to more normal levels. The primary concern to achieving the 4 hour standard is the physical capacity within the department. To mitigate against this risk the Trust is planning on an expansion of the A&E department which is due to be complete in December 16. This will support the Trusts capacity plan for winter 16/17. The Trust is seeking commissioner support of 450k to provide additional staff for the expanded A&E department. Activity and acuity tend to increase during quarter 3, while the extension to the department will not yet be complete. Therefore there is a significant risk that the physical capacity of the department will be exceeded and the Trust will be unable to meet the required standard in Q3. The Trust will try to mitigate this risk, by bringing forward its investment in additional staffing as part of the planned extension. 3.3 Priority Areas Creating capacity in the downstream wards and improving the time in which medically fit patients get discharged to the appropriate destination. Improving performance to consistently achieve the A&E 95% standard THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 6

9 Improving access to diagnostic services; as existing capacity constraints threaten cancer waiting times and RTT performance. Demand for endoscopy is expected to continue growing by, at least 13%, in 16/17. An additional specialist nurse has been recruited to address this capacity constraint, and further recruitment is planned. Maintaining performance against cancer waiting-time standards by managing diagnostic services, efficiently. Demand and capacity modelling is being applied to CT, MRI, and ultrasound services to ensure the 62-day target continues to be met. Continue to perform well against Referral to Treatment (RTT) 18 week standard. Ongoing focus on improved service development is required to maintain this position. Demand and Capacity Planning to ensure access to diagnostic services Demand and Capacity Modelling is being undertaken to inform the planning of resources for 16/17 to support cancer targets and inpatient 7 day services. This modelling is being assisted by the NHS demand and capacity training workshop and North West London 7 Day services support team who have provided funding support. There is a cancer commissioning intention in 16/17 that the Trust will be required to provide GPs in Hillingdon with an increase portfolio of direct access diagnostic services. The increased provision would relate to Abdominal Ultrasound with a maximum turnaround of 2 weeks, as well as to MRI Brain and CT Abdomen Cancer Pathways. 4 Approach to Quality Planning 4.1 Approach to Quality Improvement The Trust will implement a revised Quality and Safety Improvement Strategy this year as informed by the Trust Quality and Safety Committee s own review of effectiveness and recommendations arising from the Trust s CQC inspection in October 2014 which resulted in an overall rating of requires improvement. Re-inspection, in May 2015, resulted in the lifting of two warning notices and an improved rating for patient safety. However, a requirement notice, against regulation 12; safe care and treatment, specifically focused on infection and prevention and control, was applied and we continue to address the quality concerns raised. Persistent attention is devoted to preventing and controlling Clostridium Difficile infection. Performance is good; for although a number of cases have occurred following re-inspection; only one of them has been attributed (by Hillingdon CCG) to a lapse in the quality of care provided. Informed by this experience, we don t consider the Trust to be at risk of breaching the Clostridium Difficile target in FY 16/17. This is because the same standards of infection control will be maintained, while the protocols for monitoring performance remain extant. THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 7

10 The Trust aspires to be rated as good or above rating in future inspections; and our current approach to quality improvement is embedded in the Trusts Clinical Quality Strategy ( ). This strategy provides a structure for delivering the clinical quality governance agenda to ensure on-going improvement in the quality and safety of patient care. It is informed by regulatory and other inspections, as well as national and local priorities. The current and future strategy supports our vision To put compassionate care, safety and quality at the heart of everything we do, by defining our aims. Our 6 Quality Aims : 1. No Preventable Deaths 2. Proactively improving systems to reduce harm 3. Improving patient experience as defined by our patients 4. Achieving the best possible outcomes for patients 5. Ensuring people receive care in the right place 6. Developing a safety culture in which safety is everyone s business Quality Priorities FY16/17 Our quality priorities are aligned to the aims above and informed by emerging best practice national quality improvement initiatives which aim to: 1. Ensure early warning systems (EWS) and processes are well-organised and resourced 2. Manage strategic challenges and key quality concerns such as safer staffing and the condition of the Trust s estate 3. Develop strong clinical leadership and encourage greater patient involvement to improve services in an empowering culture that ensures that staff and patients report incidents and raise concerns about quality and patient safety in an open, blame-free working environment. We have identified four priorities for this year which are central to the delivery of our quality and safety improvement strategy. Our Quality Priorities Priority 1 - Achieve Early Warning System (EWS) compliance to support the early escalation of deteriorating patients Priority 2 - Achieve improvement in relation to seven day working priorities Priority 3 - Deliver compassionate care improving communication Priority 4 - Safer staffing improve recruitment and retention to deliver safe care THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 8

11 4.1.2 Quality Improvement Processes The Trust Board declared compliance against Monitor s Well-Led Framework in January 2016 and committed to continuing compliance with the governance requirements outlined in the framework. The Trust took into account the guidance of the responsible consultant from the Association of Medical Royal Colleges. The Executive Director of the Patient Experience and Nursing (DPEN) is the executive lead for Integrated Governance and is accountable for ensuring the delivery of a robust clinical governance system throughout the Trust which itself then ensures that the Trust delivers against its quality priorities and improvement strategy. The Trust Board receive monthly performance information against key quality and safety performance indicators, and any quality concerns which merit focused attention are highlighted by the DPEN and Medical Director. The Quality and Safety Committee (QSC) is established as a sub-committee of The Hillingdon Hospitals NHS Foundation Trust (THH) Board of Directors. It provides the Trust Board of Directors with assurance that quality and safety within the organisation is being delivered to the highest standards and that there are appropriate processes in place to identify gaps and manage them accordingly. Clinical divisions review their quality data in relation to patient safety, patient experience and clinical effectiveness on a monthly basis at their divisional governance boards; a divisional exception report is received by the Clinical Governance Committee and any concerns on quality are escalated via this committee to the QSC Top three risks to quality 1. We fail to achieve the 95% A&E four hour target leading to a breach of our Licence. 2. We fail to deliver high quality patient care as a result of inadequate staffing provision and in line with the 7-day workforce initiative. 3. We fail to meet compliance with the expected standards set out by our regulators this could impact on the Trust achieving a good rating by the CQC. To mitigate against these risks the Trust will continue to work collaboratively with Hillingdon Clinical Commissioning Group, Hillingdon Borough Council, Hillingdon Community Health and the third sector to: 1. integrate care; 2. ensure that admissions to hospital are avoided where possible; and 3. ensure that that time spent in the A&E department is reduced. The Trust will review its clinical and support service workforce using acuity and dependency tools and other mechanisms to improve frontline clinical staff numbers and care at the bedside seven days a week. The Trust will continue to drive forward a robust recruitment and retention work programme to reduce the number of vacancies and increase activity. THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 9

12 The Trust will continue to strengthen its governance arrangements and its compliance with the Health and Social Care Act regulations through a programme of internal peer review and mock inspection ensuring there is evidence of progress of improvement against a refreshed CQC action plan for 2016/17. There will be increased scrutiny of operational performance and quality data and a new accountability framework to ensure compliance with policy and delivery of statutory targets. Particular attention will be devoted to areas of outstanding compliance notices, most notable of which is infection control Sign up to Safety Plan The Trust joined the Sign up to Safety campaign with a commitment to reduce avoidable harm by 50% by April The Trust outlined what actions it will undertake in response to the five Sign up to Safety pledges to: Put safety first Continually learn Honesty and transparency Collaboration Support Our focus on harm reduction for 2016/17 will be to: 1. Reduce the number of hospital acquired pressure ulcers 2. Reduce the number of inpatient falls 3. Improve medication safety; and 4. Improve the care of the acutely ill older person. 4.2 Seven Day Services The Trust is a part of the North West London early adopter programme for national seven day services standards and as such will implement an action from 1st April 2016 working with partners across North West London plan to become compliant with all standards. A clinically-led governance structure is in place to gain assurance of compliance with the 10 clinical standards: the steering group has a consultant chair and the Trust medical director appointed as executive lead. Each of the Trust s 4 clinical divisions owns its own action plan to deliver compliance with national standards within their overall annual divisional business plan. 4 standards have been identified nationally as a priority: THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 10

13 Seven Day National Priorities Standard 2: Time to first consultant review Standard 5: Access to Diagnostics Standard 6: Access to Consultant Directed Interventions Standard 8: On-going Review (planned for 16/17-see below) These 4 standards are expected to form CQUINs and be included in our 16/17 contract with HCCG and be included in the Sustainability and Transformation Plan. The Trust has undertaken a detailed and accurate baseline assessment of performance against these standards in order to identify gaps in existing service. These have been classified to highlight two areas in which focused attention is required: organisational development and changes to working methods additional investment, in staffing or other infrastructure changes A second baseline assessment is underway against the remaining 6 standards. Against Standard 8 - ongoing review for patients in high dependency areas who must be reviewed by a consultant twice a day- the Trust is working with clinicians across North West London to implement these. This will pose some challenges due to: The cost of consultant cover proving to be prohibitively high in the currently financially challenged environment The available numbers of consultants inhibiting North West London providers ability to provide sufficient cover under existing models of care There is a programme of work under the Hillingdon Better Care Fund to address Standard 9, seven day discharges. The Trust and local partners have developed a multi-disciplinary action plan, to facilitate transfer from the acute setting to primary, community and social care seven days a week. 4.3 Quality Impact Assessment Process Cost Improvement Programmes (CIPs) and quality improvement programmes are identified and developed by the Divisions and Executive Leads in partnership with the Programme Management Office (PMO). They are underpinned by a Trust wide improvement approach which is based on best practice and benchmarking. They are also aligned with North West London sector wide programmes and the outcomes of the Lord Carter analyses. Together they plan improvement in safety and quality whilst delivering greater process efficiencies and to financial improvement outcomes. Divisional project leads complete a Project Initiation Document (PID) within which there is a Quality Impact Assessment (QIA). Together this information describes the scheme, defines benefits and captures the action plan for delivery and associated risks. Divisional Director (a medical consultant in the division), Divisional Assistant Director, Assistant Director of Nursing and Divisional Finance Manager and HR, if applicable review and sign off all plans. THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 11

14 If the PID for a programme or service development identifies any scheme as having a significant and potential quality and or safety impact, a more detailed QIA is completed and reviewed by a Clinical Assurance Panel (CAP). This happens if: The scheme is Trust wide There is an assessed risk of 10 or higher The PMO have identified that there is a greater risk identified against the programme when considered in parallel to other schemes. The Divisional Leadership Team is unable to collectively sign it off. The CAP is chaired by the Medical Director and comprises a Divisional Director, the Director of Transformation, a Clinical Governance representative, 3 additional Clinical representatives and a Nursing representative. The CAP scrutinise submissions and agrees whether the programme can be progressed. The CAP will report to Board s Transformation Committee twice a year that due consideration has been given to any potential clinical or quality risks to the programme and that there is a clear plan in place to mitigate any such risks. A formal report is submitted to the Trust Board annually. Within each Division, there will be a dashboard for each programme summarising the PID, QIA, and Key Performance Indicators (KPIs) against an agreed methodology and agreement of measurement. The programme board and or the divisional boards will monitor the progress against KPIs, supported by the PMO monthly. 4.4 Triangulation of Indicators Approach to triangulation Triangulation of quality, workforce and financial indicators is central to the annual planning process. Performance monitoring occurs throughout the year at board and divisional level. Monthly, the board receives an integrated quality and performance report, setting out detailed metrics demonstrating quality performance and workforce data. This is reported alongside the monthly finance report, to give a full overview of monthly performance. Quarterly, a board report highlights performance against the outlined year s strategic objective, which provides a narrative on the priority information in each of these areas. Performance against these KPIs of clinical divisions is reviewed by executives and the senior management team, throughout the year. For clinical divisions, this happens quarterly. For supporting departments reviews are held bi-annually. The structure of each divisional team is designed to provide the most coherent possible leadership. Each divisional director is a consultant within the division, providing clinical oversight working in a triumvirate with a senior operational manager (Assistant Director of Operations (ADO)) and a senior nurse (Assistant Director, Nursing (ADN)) and supported by operational management, business development, nursing, financial management and HR teams for each division. Each divisional review involves the divisional team, with all executive directors present, and provides a comprehensive review of quality, workforce and THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 12

15 financial performance, identifying issues and risks and actions to address. Further commentary is provided in section 5.11, below Key Indicators Indicators in monthly integrated quality and performance report reflect the core principles of the five Domains set out in the Care Quality Commission's Intelligent Monitoring System (i.e. Caring, Well-led, Effective, Safe and Responsive). Relevant indicators are also reflected in a balanced scorecard produced by each clinical division. The principal, cross-cutting indicators include: Workforce: vacancy rate, use of agency staff, STAM compliance, sickness rate, turnover rate, and staff expenditure. Care quality: The quality indicators for the Trust vary from division to division and are reported as part of a balanced scorecard. Financial: Income and expenditure compared to plan; balance sheet and cash flow; as well as the Trust s overall financial sustainability risk rating, which includes liquidity, debt service. The board also receives more detailed financial appendices Use of information Triangulation indicators are used at a board level to assess progress against strategy and highlight areas of risk or non-compliance. At the divisional level, they inform action points and focus attention on immediate priorities. Where particular challenges are highlighted, the board arranges follow-up meetings and working groups to address areas of concern. The outcomes from this process informs the Trust risk register, which is updated regularly. 5 Approach to Workforce Planning 5.1 Approach to workforce planning with clinical engagement Our clinical workforce is at the forefront of care and will continue to lead and drive workforce planning. In 2015/16, the Trust moved to a clinically lead divisional structure, with the director of each clinical division a consultant within that division, supported by an assistant director of nursing and an assistant director of operations. The development of Trust workforce plans involves these teams and ensures that views of our clinical workforce are included, along with a top level executive steer. In 2016/2017, our workforce planning approach will be geared to building clinical capability by driving learning from integrated care pilots. The Trust understands the investment in ongoing development of strong leadership and management necessary for clinical staff to involve themselves actively in workforce planning and to lead services and highly performing multidisciplinary teams. In 2016/17 we will: THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 13

16 Increase our extensive range of leadership and management programmes such as Leadership 100, inspired to lead, inspired to care and stepping up programme Launch our new Managers Development programme Our new Management Charter will be at heart of this new programme setting a standard of attitudes and behaviours essential for good management at the Trust. Continue to enrich the experience of trainee doctors, student nurses and Allied Health Professionals We value the voice of our staff and commit to involving them in decisions about patient care and services. We will continue to act on feedback from the Staff Friends and Family Test and the annual staff survey, working to better understand staff requirements, build a culture of learning and support teams locally. Working in partnership with our GP and community partners, we will continue to promote opportunities that support a community of shared learning through initiatives such as the paired learning programme and experiential learning 5.2 Governance process of board approval of workforce plans Our workforce is key to our ability to deliver our strategic vision and operational plans. In the last year, the trust has strengthened workforce governance structures, which have provided the strategic focus and scrutiny necessary to deliver of our workforce transformation plans. Workforce plans are developed at a divisional level, led by the divisional director with input from the assistant director of operations and assistant director of nursing, supported by the HR lead for each division. These workforce plans are collected, with feedback, by the Head of workforce planning and organisational development. After this input, plans are presented to Trust board by the executive director of people for approval. This process ensures input from relevant clinical, operational and corporate teams, making plans reflective of the clinical environment and issues affecting the Trust as a whole. 5.3 Link to clinical strategies and commissioning strategies Generation of workforce plans at divisional level ensures that service demands and pressures are fully accounted for as they are developed and that they are aligned to safe staffing workforce requirements and receive clinical input. The Trust is heavily involved with the sector-wide Shaping a Healthier Future (SaHF) programme. As such, workforce plans are based on projections agreed by all local commissioners and providers. The workforce requirements of certain services, such cardiology, respiratory and diabetes are subject to commissioner led developments, such as integration with community services. Trust workforce development plans reflect these initiatives and ensure that commissioners are aware of the staffing and funding required for certain services. The Trust workforce plans also reflect sector wide initiatives, such as early adopter status for national clinical 7 day standards (see section 4.2), whole systems integrated care work and the setting up of a pathology joint venture across North West London providers. THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 14

17 5.4 Local workforce transformation programmes and productivity schemes In 2016/17, we will deliver year two of our workforce transformation strategy, driven by the following programmes: Recruitment & Temporary Staffing Working Group (particularly nursing focussed) Retention & Engagement Working Group (all staff groups) People Management & Productivity Working Group (all staff groups) Future Workforce Models Working Group (all staff groups) The Trust transformation programme ties in with and informs North West London sector wide transformation work being undertaken by McKinsey, divided into 5 work streams: End of Life, Orthopaedics, Bank and Agency, Procurement and Improvement Approach. To bridge the gap between workforce demand and market supply, (particularly our registered workforce) and historical skills shortages, we will expand current investment in new roles such as advanced, associate practitioner and physician associate roles. The current proposal to create associate nurse roles will provide an ideal opportunity for the Trust to extent our Talent for Care initiative and support the career pathway to qualified nursing careers where required. 5.5 Effective use of e-rostering and reduction in agency staffing To ensure that the Trust makes best use of e-rostering data; the People Management & Productivity working group has set up a new report format, to allow for front line managers and divisional to have easier access to information relating to staff. A restructuring process has moved the e-rostering under the supervision of the director of transformation, to allow for a greater integration with the Trust-wide integration programme. The agency rules regarding the use of agency staff have supported the initiatives taken by the Trust with regard to reducing the Trust s reliance on agency staff and particularly the use of off-framework staff. Initiatives include: Rolling recruitment Recruitment open days Targeted campaigns in hard to recruit areas EU recruitment drives Introduction of a substantive pay rate for substantive bank staff Restrictions on off framework Move of medical staff from off payroll to payroll Centralising medical staffing (in progress) 5.6 Alignment with HENWL We have a strong working relationship with Health Education North West London (HENWL) and we will continue to work in partnership with them in supporting education commissioning, essential for sustaining clinical placements and growing the next generation of healthcare professionals. THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 15

18 In 2016 we will progress our collaboration with HENWL and CCGs/Boroughs in building system wide workforce planning capacity and capability to ensure detailed understanding of the current and future workforce. This work will be central to the development of innovative workforce models and solutions for the future. Currently, the relationship with HENWL is focused on developing system-wide workforce planning capability. 5.7 Triangulation of quality and safety metrics with workforce indicators HR divisional representatives provide information for the Trust s quality and safety indicators triangulation process. The information is provided monthly, in the divisional balanced scorecards; and reviewed quarterly, by the Trust executive. It informs the Integrated Quality & Performance Report which triangulates quality, safety and workforce indicators. The HR representatives work with the divisional directors, assistant directors of operations, assistant directors of nursing and other clinical leads. They identify areas with especially high vacancies, sickness or turnover; and triangulate this with clinical indicators for that area. They develop action plans to address recognised trends, and may involve central team support. HR and the nursing directorate liaise to compile and analyse HR metrics which support safer staffing work, identify risks, and enable decisions to be made. 5.8 Application and monitoring of QIAs for all workforce CIPs The workforce team work closely with the PMO in the application of the quality impact assessment process described in section 4.3 of this document. Each clinical division has a dedicated HR lead responsible for supporting the divisional teams in the implementation and oversight of all quality impact assessments relating to workforce. 5.9 Workforce initiatives as part of the 5 year forward view The Five Year Forward View has provided the national vision for healthcare or the future. Our workforce plans are informed by this vision, the integrated care system agenda, seven day services and Shaping a Healthier Future, which present workforce development implications for the trust. Locally, this will require a section of our workforce working differently. Over the next two years, this will include: Supporting the development of both highly skilled clinical specialist and generalist roles to resource the movement to care out of hospitals, where appropriate. The development of new roles (such as Advanced Practitioner roles) which will be instrumental to implementing the standards necessary to deliver care seven days Creating peripatetic medical and nursing roles that will enable clinicians to work flexibly in highly performing teams for the benefit of patients, such as perioperative practitioner and occupational therapy assistant practitioner roles for theatres. This will potentially include roles working across multiple local providers. Continuing to implement consultant-led services, particularly in Emergency Care. Expanding our research excellence and strengthen our academic and education partnership, working with local partners like Brunel University London, to build on an education and learning hub, attracting clinical fellows and graduate trainees THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 16

19 Creating apprenticeship roles, extending current provision in clinical roles to provide long lasting careers through apprenticeships in areas such as estates and facilities and corporate directorate Implementing our healthier staffing strategy to improve the lives of our staff Increasing use of learning technologies and digital learning, improving access to opportunities and communication of practice 5.10 Balancing agency rules with achievement of appropriate staffing levels Strong workforce governance structures locally provide the framework and scrutiny to maintain and sustain appropriate safe staffing levels within clinical areas. Where safe staffing levels are put at risk and there is a necessity to go off framework it requires approval from an executive director before engaging such staff and will be reported to Monitor Systems to regularly review and address workforce risk areas We will continue to review and manage our workforce risks (particularly resourcing) to ensure our plans are sufficiently robust and responsive to meet changing patient and workforce skills requirements. Work is currently underway to rationalise reports and streamline the process, whilst maintaining the current strong level of oversight. Divisional team meetings keep a track of all workforce metrics, identifying risks to individual areas and creating action plans as appropriate. These metrics are provided to the divisional teams as part of a people dashboard, with the HR lead for each division able to provide detailed analysis and information to each team. The executive directors monitor this performance at monthly and quarterly divisional review meetings and provide necessary challenge. On a Trust wide basis, high level workforce risks are a part of the Trust risk register. Particularly attention on a Trust wide level is given to areas of priority, such as the Trust Action Plan following CQC inspections in 2014 and Our key workforce priorities for FY16/17: 1. Improve workforce retention to support band development particularly within nursing and therapy roles. 2. Establish apprenticeship schemes, to build capacity in hard to recruit areas, grow the workforce and bring talent and innovation into the organisation. 3. Provide work-experience placements for people with learning disabilities in conjunction with inclusive employers. 4. Support worker and advanced practitioner roles to support the integration agenda seven day services and new ways of working. THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 17

20 6 Approach to Financial Planning 6.1 Financial Forecasts and Modelling In 2016/17 the Trust is planning to deliver a deficit of 1.9m. The forecast is based on robust local modelling and is informed by planning assumptions aligned to both national expectations and local circumstance Sustainability and Transformation Fund Although, much needed for medium-term financial sustainability, the Trust is currently unable to achieve the 10.0m surplus control total proposed by NHS Improvement. Consequently, we would not be able to benefit from the 6.7m of sustainability and transformation funding. This is despite a stretch QIPP being set that is greater than included in the draft plan. The 10.1m underlying deficit in 2015/16 has not been taken into account in calculating the proposed control total. To achieve the control total, the Trust would have to plan to deliver a QIPP that would be unachievable and not clinically safe Key movements in revenue and expenditure In 2016/17 the Trust will have to invest at least a further 1.5m in service quality to meet the full-year effect commitments from existing quality investments and provide the necessary resource to achieve 85% of CQUINs, as assumed within the plan. Funding of additional quality investment during 2016/17 is not affordable and has not been assumed within the plan. Indeed, this commitment is required during a period of declining revenue, for the Trust will experience a 1.3m decline in net revenue in the coming year. This is because an intermediate care service, which the Trust had supplied to another provider in North West London, is being decommissioned. The modelling of activity assumptions is consistent with the approach employed by the Shaping a Healthier Future programme of North West London. This 5 year plan brings the Trust into recurrent financial balance over a 5 year period. Achieving financial balance, however, will require additional funding for a number of one-off investments to reduce overall running costs. These include: Sector-wide pathology joint venture start-up and transition costs A&E short-term expansion Health-economy outpatient prescribing transformation Hospital electronic prescribing Electronic document management The costs and benefits of these initiatives will be further refined and included in the 5-year integrated health economy plan currently being developed. Following negotiations with our Host Commissioner a further 3.0m of commissioner support has been agreed and is included within our plan. This increases the total value of commissioner support in 2016/17 to 5.0m. THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 18

21 6.1.3 Financial pressure 2016/17 will be characterised by increased costs, falling revenues, and an inadequate capital expenditure. A deficit of 1.9m. is forecast. The Trust s financial sustainability risk rating will remain at 2 overall, but liquidity will remain at 1 unless access to the 6.7m of sustainability and transformation funding is granted and additional SaHF transition funding agreed. In order for the Trust to return to a financial stability, both in terms of revenue and liquidity, the Trust will need access to the 6.7m sustainability and transformation funding offered, which will require recognition of the recurrent underlying financial position within the control total. 6.2 Efficiency Savings for 2016/17 The Trust has completed a QIPP Efficiency savings for years 2016/17, 2017/18, and an outline plan for the three years following to The total value of this QIPP plan is 44.2m. This is a variance from the value identified in the forecast section (6.1) as the plan includes the primary Figure 1 target, an allowance for contingency related to underachievement, and redresses the expected shortfall from the 2015/16 programme. The QIPP phasing of requirements is shown at figure 1. The delivery plans are informed by coordinated work across North West London and reflect the Trust s activity plans for FY 16/17. In addition, they incorporate the 2015/16 year to date spend, Monitor regulation, Lord Carter opportunity identification and further benchmarking information. Delivery plans have been developed in partnership with all divisions Figure 2 Valuation and are underpinned by a Trust wide 2016 / 17 Requirement 9.80m improvement approach. Total value of Value Identified 9.14m schemes identified to date is shown at figure Remaining Gap 660k 2, and the distribution of these schemes by theme at figure 3. Pay schemes include controls on use of agency, including a reduction in nursing agency expenditure as a percentage of total spend from 12% to 9%. The plans also take into account the calculated effect of the agency cap on pay spend across all groups. Pay savings are also predicated on the reduction of expenditure associated with reducing the Trust total bed base. THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 19

22 Non-pay schemes include procurement schemes, in particular relation to theatre equipment, drugs, and business practice efficiencies. The identified income schemes are related to known sources of income which are planned for realistion in 2016/17, and take into account the effect of the block contract with Hillingdon CCG. The Trust has established a number of Transformational change programmes, both internally focussed and working with local partners. The Trust is actively participating in a number of sector wide transformation programmes which will also contribute savings to the overall requirements. In addition, further cost improvement schemes are in the process of development to close the gap between the requirement and value identified. To provide greater assurance on the delivery of future QIPP savings, the Trust has been rigorous in implementing the findings of CQC Root Cause Analysis. Figure Lord Carter s Provider Productivity Work Programme Lord Carter wrote to the the Trust, in December 2015, deliniating opportunities for efficiencies across the operational spend of the organisation. In developing the QIPP plans for 2016/17 and beyond, the Lord Carter calculations have been considered and potential savings identified. There were four major areas considered by Lord Carter in the NHS Productivity and Efficency Programme Projects within the Autumn 2015 Model Hospital Data Pack: Hospital Pharmacy and Medicines Optimisation (HoPMOP) Estates and Facilities Ward Nursing Workforce Procurement. HoPMOP: The pack identified that Trust total costs for HoPMOP were 8% below the model hospital simulated costs. Staff costs, when London weighting is taken into account, are at or below national average, and medicine costs are below national average. Despite this indication of relative efficieny from the Lord Carter work, the Trust believes that savings of 250k are achieveable in this area. Estates and Facilities: The Trust is shown to be relatively productive and efficient in its management of the estate, and in facilities management (8 of the 12 indicators are green). However, the review also highlights considerable issues in relation to the infrastructure risk and the backlog maintainance of the estate quality. These risks are acknowledged by the Trust, and options for addressing the issues are being developed through the Master Planning process. This initiative examines the use of, and potential values to be derived from, the entire trust estate. It involves developing prioritised proposals for capital projects to address deficiencies and maximise estate useage. THHFT Operational Plan FY16-17 Publication iss1.0 (signed) Page 20