North East London NHS Foundation Trust

Transcription

1 Forward Plan Strategy Document for North East London NHS Foundation Trust

2 Forward Plan for y/e 31 March 2013 (and 2014, 2015) This document completed by (and Monitor queries to be directed to): Name LES BORRETT Job Title address EXECUTIVE DIRECTOR OF FINANCE Tel. no. for contact ext 4303 Date 22 May 2012 Approved on behalf of the Board of s by: Name (Chair) JANE ATKINSON Signature Approved on behalf of the Board of s by: Name (Chief ) JOHN BROUDER Signature Approved on behalf of the Board of s by: Name ( ) LES BORRETT Signature

3 Section 1: Forward Plan A. The Trust s vision is summarised as: Summary North East London NHS Foundation Trust (NELFT) is a provider of both mental health and community health services. Mental health services (MHS) are provided to four London Boroughs, i.e. Redbridge, Waltham Forest, Barking & Dagenham and Havering, with some Specialist Services also provided to Essex and East London. Following recent acquisitions we have grown in size to be a 300million + organisation, serving a population of 1.5 million. With an established reputation as an innovative, high performing organisation we are committed to working with commissioners and local health and social care partners to contribute to solutions in the wider local health care system in which we operate. This includes exploring collaborative models of care, seeking to significantly reduce demand on acute care facilities and providing more treatment in a community setting. NELFTs solid performance across governance/quality and financial domains will serve as a strong foundation on which to build, as we explore opportunities for growth in the care and treatment of patients in the community eg patients with long term conditions. Our recently launched organisation wide transformation programme will assist with consolidating our service portfolio whilst maximising opportunities and synergies from our recent acquisitions. Furthermore, we will continue to focus on improving quality, and ensuring good value for money, aiming for positive patient outcomes and experience, across all our services. Strategic overview and corporate objectives Our strategic aim is to create service design solutions for this population that enables treatment at home or in the local community through collaborative models that utilise pro-active care management programmes. We will work with partners (including academic institutions) to embed evidence based care that truly transforms the services, draws resources out of acute care to the communities we serve, creating a one stop patient experience with choice and enhanced quality of care. We aspire to be cited by all stakeholders as a people based organisation making a genuine difference that truly values people in whatever way they interact with the organisation. This includes patients, our staff, partners and commissioners We will continue our development and interest in the use of emergent technology to enhance the patient experience, using contemporary approaches to clinical intervention and use our substantial research portfolio to contribute to continuous improvement in the quality and effectiveness of our patient experience. Our focus on quality will continue to develop such that we will build on our unique models of patient involvement and influence and ensure that patient experience continues to feed in to the future planning, design, and evaluation of our clinical services. Our financial position remains strong and to date we have been able to maintain our planned financial ratings. In light of our acquisitive history the portfolio has changed and maintaining our EBITDA would require us to generate a much harsher demand on our cost improvement programme. On balance, the Board takes the view that we would serve our patients and other stakeholders much better by reducing our expectation and planning an FRR of 3 in 20. We will deliver a demanding cost improvement plan in year and deliver a surplus in each of our business units. The Trust has established five key strategic objectives underpinned by key priorities/initiatives to assure delivery of our vision. These corporate objectives have been developed from Board workshops and other forum in which we have agreed development or collaboration plans to build on what we have achieved to date. The objectives have been set against the backdrop of the financial and operating challenges that are faced within the local health economies. The key aim is to improve the quality of care provided by our services and to ensure maximum value for money is achieved.

4 Whilst both the local economies face challenges, there are areas of opportunities where NELFT can assist with making a significant impact to improve local services, e.g. playing a critical role in supporting more care in the community, reducing length of stay in acute and community hospitals, along with improving the pathway of care for patients with complex or long term conditions. NELFT s vision is to be the provider of choice for the populations of ONEL and SWE, working to redesign our services and develop our staff, enabling us to deliver year on year increase of the number of patients cared for within the community setting (or in their own homes). Our teams will work jointly with partner organisations to integrate care towards reducing emergency admissions and ensuring that where people are admitted to hospital, their stay is as short as possible. Furthermore, we will increase our focus on managing patients with more complex/ long terms conditions maximising quality in everything we do. This vision will be realised through successful delivery of our corporate objectives as outlined below :- Corporate Objectives and rationale Improve service quality & productivity Delivered through :- Implementation of framework for care (clinical strategy) - aiming to demonstrate that the services we provide are safe, high quality and deliver effective care. Implementation of mobile working strategy - aiming to act as an enabler to services provided in the community, improving productivity and in turn enabling more people to be cared for at home. Deliver service transformation and improve local environments Delivered through :- Progressing the Quest4Excellence transformation programme - aiming to ensure we deliver high quality and effective care, furthermore, redesigning services to respond to spending cuts by being innovative in transforming the services we provide. Progressing the Health4NEL joint initiatives - aiming to work jointly with partner organisations to redesign services and establish new services that reduce hospital admissions, and enabling more patients to be cared for in their own home. Implementing the estates strategy - aiming to ensure we have the right facilities to deliver our services and where possible find ways to rationalise the use of estate to maximise value for money and reduce overhead costs. Deliver improvements on financial and performance targets Delivered through :- Delivering against contractual requirements (e.g. MONITOR, CQUIN,, KPIs) - aiming to demonstrate to commissioners our ability to deliver against agreed targets and delivery of high quality, effective services. Deliver new business opportunities Delivered through :- Implementation of the commercial strategy - aiming to identify core vs non-core business, enabling us to use intelligent data/information to establish the quality of the services we provide and making decisions on services to grow and those which we may have merits in discontinuing. Implementation of communication strategy - aiming to ensure good communication internally and externally to maintain the NELFT reputation and brand. Supporting the relationship management between new emerging Clinical Commissioning Groups (CCGs) and furthermore, to enable us to communicate good practice and innovation across the organisation. Improve capability and capacity Delivered through :- Implementation of the workforce strategy - aiming to ensure the right capacity and capability exists within the organisation to support high quality service delivery. Furthermore, taking account of innovative service solutions required to care for more patients in the community, and reducing

5 the requirement for acute hospital care. This is likely to require innovative workforce solutions to attract /or develop more advanced skills within our teams. Implementation of the informatics strategy - aiming to support the delivery of more care being delivered in the community with the right technology available to our teams, enabling clinicians and teams to be able to communicate effectively with colleagues across services and organizational boundaries. B. The Trust s strategic position is summarised as: As we begin to see the full impact of the recession on public services, NELFT has seen significant growth in its business base with the acquisition of SWECS and NELCS in The performance of services against contracted targets was maintained throughout the previous financial year and there have been no material variances between planned and actual performance. The financial position remained stable throughout. Overall, we will not see major change in the existing business portfolio in the year ahead and look forward to a period of integration and consolidation. Major contracts have been agreed with no uplift and we are therefore absorbing all inflationary elements of the business through cost improvement programmes and efficiencies. The year ahead will see a standstill or minor change position against the majority of existing contracts, but we will continue to bid for appropriate services as opportunities arise and respond to the contestability programmes of NHS NELC and NHS South Essex. NELFT holds a strong position in terms of financial standing and reputation for delivery as evidenced by its community health service acquisitions in recent years. Even those services excluded from the ONEL Services acquisition on the grounds of competition (i.e. Redbridge Children s Services and Redbridge and Waltham Forest Dentistry Services) have now seen NELFT successfully named as preferred provider, following a competitive tendered process. These services, will form part of the NELCS business unit following appropriate due diligence during 20. In contrast, our neighbouring acute Trust (Barking, Havering & Redbridge University Trust) has financial challenges and it is envisaged that by our engagement in the Health4NEL programme there will be opportunities to implement new service models which maximise out of hospital care In the SWE Health economy there is a challenging PCT cluster QIPP plan with key areas of focus on reducing acute hospital activity and emergency admissions. This provides the SWECS business unit with an opportunity to increase the number of patients cared for within community services and we are working closely with the cluster to support delivery of the QIPP plan. The PCT cluster has already commenced a process of handover to CCG s; as such we are developing strategic relationships with key stakeholders. The priority areas that we are focusing on include unplanned care and the frail elderly pathway. SWECS are working closely with partner organisations, including social care, to reduce the pressure on the acute system whilst maintaining a strong position within the local health economy, continuing to monitor for new business opportunities along with any risks around contestability of services. The financial risk of commissioner contestability plans have been estimated to be low risk in financial year, as there are no further significant services expected to be contested. To mitigate such potential risks in later years, transformation programmes have been prioritised and are in progress to ensure service lines are competitive. Furthermore, we are preparing our services so they are in a position to respond to opportunities as they emerge under the Any Qualified Provider (AQP) initiatives and we are progressing our commercial strategy. NELFT is committed to maintaining and developing good relationships with PCTs and GPs (emerging CCGs) via regular contract review meetings and progressing our GP Engagement Strategy. We are also exploring joint projects with local acute providers where there are opportunities to improve the pathways of care through more integrated service delivery models and we have recently been selected by the NHS Institute for Innovation and Improvement to participate in a large scale change initiative with a joint senior team from NELFT and our local acute hospital. Clinical and Quality Strategy C. The Trust s Clinical and Quality strategy over the next three years is:

6 The Chief Nurse and Mental Health Services is the lead with responsibility for clinical and quality strategy. The basis of NELFT s Clinical and Quality strategy over the next three years is contained in our recently developed Framework for Care The Framework for Care is designed to draw together a number of inter-related work streams into a coherent service wide development framework that will set the direction of travel for clinical development across NELFT for the next 3 years. It sets out the clinical standards that reflect the priorities of the organisation in relation to our patients/clients and it will enable us to benchmark against these standards and develop plans to ensure that all key areas of clinical development and governance are achieved. The Framework aims to :- Enable patients/clients to make choices about their care and improve their quality of life Provide the necessary programme of care, treatment, support and advice that addresses all the factors that contribute to an individual s physical, psychological and social well being Through the principle of Clinical Governance, improve the provision of care through the implementation of evidence based practice. We are driven by one overarching aim - to deliver the best possible service for our patients. The Framework covers five broad areas of the clinical and quality agenda :- 1. Patient involvement and experience 2. Patient Safety 3. Clinical Pathways 4. Professional Integrity/Leadership 5. and Innovation 1. Patient involvement and experience Key principles/sub strategies Care will be delivered with dignity and respect, staff will be honest and open about what can and cannot be done. Detailed, timely and up to date information will be shared about patient care, including access when our services are needed urgently. All patients/clients will be involved in decisions about their care No decision made about me, without me. Concerns will be listened to and acted on appropriately. Staff will ensure that our practice is sensitive to cultural lifestyle differences, and is open to other perspectives. Written information will be available in community languages and interpreters for service users and carers will be available where required. Staff will work with patients/clients to develop and improve service provision. Care will be delivered in an environment that is supportive, comfortable and therapeutic. Our services will be responsive to the population we serve. Measures of success Year on Year improvements in clinical environments, measured by local and national surveys e.g. Quality Account objectives. National Audits completed e.g. MCA Increase patient involvement in service provision initiatives. Every aspect, from policies to practice and service improvement to redesign can show there has been an equality impact assessment. Patient reported outcome measures. Increase in compliments. 2. Patient Safety Key principles/sub strategies To develop a proactive approach to safety. To build trust and confidence in the services provided. To listen to, respond to and learn from peoples experiences. To be vigilant through robust safeguarding processes. Measures of success An increase in the level of Datix incident reporting.

7 Benchmark services with other organisations, locally and nationally through participating in the QIPP Safety Thermometer. Implementation of the clinical competency framework across the organisation. Year on year reduction in serious incidents. Year on year reduction in complaints. Evidence of feedback and lessons learned with improvement plans completed. Reporting on key objectives set within the Quality Accounts. Evidence of improved patient reported outcomes. 3. Clinical Pathways Key principles/sub strategies Greater focus on front line clinical care and the staff who provide it. To work with patients and their families, our partner clinicians and organisations to design clinical. pathways that are easier to navigate, focus on continuity of care and add value to treatment and wellbeing. To particularly focus on patient partnerships based on a move away from the sickness service model, to supporting health and wellbeing, embracing the role of supporting self-care. To provide care that is based on best available clinical evidence. Measures of success Using outcome focused care to measure the effectiveness of patient interventions. A reduction in unplanned admissions. New integrated clinical care pathways, developed with partner organisations. All care pathways provided are measured against best practice evidence and public health data. Evidence of staff promoting self-care with individuals, families and carers. Children and families transferring to adult services report a smooth transition. 4. Professional Integrity/Leadership Key principles/sub strategies The organisation will support professional development where clear links to organisational values, priorities and/ or professional codes of conduct are identified. Clinicians with the capability and willingness to develop will be supported and given opportunities to let their talent flourish. Staff will work with partners to develop a broad range of educational and developmental opportunities. A clear career pathway for clinicians will be developed that encourages and rewards personal development initiatives whilst providing a framework which will nurture such learning. Links will be strengthened between clinical directorates and encourage multi professional working, create a culture where contribution is welcomed, talent is recognised and success is celebrated. Develop a culture that empowers, values and is respectful of its staff and thus encouraging identification and management of issues of poor practice. Establish robust workforce planning processes to deliver the workforce of the future. To support the education of pre-registration students within our clinical services. Measures of success Year on year improvement in appraisal and mandatory training uptake. Year on year improvement in national and local satisfaction survey results. Implementation of a competency framework. Reduction in staff turnover, sickness and absence. A relevant training prospectus of training is available for all. Positive feedback from our student population. Positive evaluation of training. Support structures in place to enable career progression. 5. and Innovation Key principles/sub strategies Innovation will be promoted within all services in order to improve the quality, safety and

8 efficiency of patient/client care. Introduction, support and integration of new models, tools and approaches to delivery and monitoring of patient care will be integrated to patient/client care according to their relevance to the service areas e.g. High Impact Actions, Safety Thermometer. Teams, services and clinicians will be supported and encouraged to explore new ways of working that improves care delivery through application of new evidenced based practice, innovative approaches, application of research to workplace. Service user engagement in service redesign is essential and various models for this will be explored and introduced including collaboration with service users, experience based design and expert patient. Staff will be empowered and supported to gain confidence in developing new ideas, products, undertaking research or projects that contribute to the improvement of the patient outcomes/experience, staff, and organisation. Staff engagement and use of innovation to enhance patient/client outcomes, improve service delivery or staff experience will be promoted, recognised and shared across the organisation internally and externally. Measures of success Clinical measures are integrated throughout care delivery, ensuring they do not detract from direct patient/client care or their experience. Increased clinical productivity that can be evidenced through on going service reviews and benchmarking. Continued success of the staff award programme. Continued support and engagement in the clinical effectiveness day where innovation in practice can be showcased. Local and national recognition for new or improved services through awards, publication or sharing best practice. Staff actively involved and supported in participating or undertaking research. One new idea per quarter implemented or evaluated/audited within service. Going hand in hand with the Clinical Strategy is our Quality Account which has been informed by sources within the Trust, from frontline staff to the Trust Board, by external stakeholders and the public. We have listened to views on the services we deliver well and to those identifying areas where improvements are needed. Five hundred and sixty five returned quality account consultation questionnaires, along with areas identified through complaints, have directly informed our improvement priorities for 20. NELFT is determined that its focus on quality improvement is the same as that given to maintaining financial balance. We believe that quality is the responsibility of every member of staff and we have established systems to ensure that quality is embedded at an individual, team, business unit and Trust Board level. We have implemented a strategic, inclusive approach to both ensuring and assuring high levels of care through our governance processes. Our corporate objectives are aligned and consistent with our commitment to delivering quality services. Clinical and Quality priorities and milestones D. Clinical and Quality priorities and milestones over the next three years are: In section C above we described our clinical and quality strategy and key priorities for the next 3 years. In addition each of the business units have 3 quality priorities under the 3 domains of quality (patient experience, safety, and clinical effectiveness) identified through stakeholder engagement in developing our quality accounts. These are outlined below along with the CQUIN quality priorities for each business unit for (agreed with commissioners). The Board will gain assurance against delivery of the quality priorities through the Quality and Safety Committee who review key quality indicators from each business unit on a monthly quality and safety dashboard performance report. Quality issues and measures Contributio n to the strategy Key actions and delivery risk 3 year targets / measures for 20, 2013/14, 2014/15

9 Quality domain: Service User Experience Improved communication between staff and service users/patients (Quality Account priority) Improve service quality, productivity and staff capability MHS Business Unit:- Key actions: Robust use of CPA policy including care planning Continued monitoring of Essential Standards Staff charter used in supervision Supervision monitoring Appraisal monitoring Potential delivery risk for appraisal monitoring- incomplete data capture if electronic system not fully utilised. Mitigation, new appraisals approach developed and cascaded to manager, quarterly reporting of appraisal update to identify any early gaps How progress will be measured: MHS Business Unit:- Monitoring of KPI s Seven day follow up Monitoring of quality in supervision Internal CQC inspections (13/14,14/15) Monitoring appraisals through e-ksf (13/14,14/15) Audit of patient protected time Results of National Patient Survey (13/14,14/15) SWECS Business Unit:- Key actions: Each team leader to review systems and processes regarding communication with patients and agree one action to improve communication in relation to CQC outcomes: 1. Respecting and involving people who use services 2. Management of medicines SWECS Business Unit:- Number of complaints and compliments received (13/14,14/15) Quarterly summary report to Service Patient survey (13/14.14/15) Potential risk all staff not delivering sufficient information to patients re medicines management. Mitigated with clear communication to staff of expectations and monitoring success NELCS Business Unit:- Key actions: Action plans from complaints Action plans from serious incidents Customer care training implemented Operational direction Linkage to appraisals/supervision/team meetings NELCS Business Unit:- Number of complaints and compliments received (13/14, 14/15) Patient survey (13/14,14/15) Potential risk- management restructure following acquisition may cause delay with achieving consistency across Borough s. Mitigated with clear communication of expectations and early evaluation of

10 success. Quality Domain Patient Safety Improved waiting time from referral to first contact with our services (Quality Account priority) Improve service quality, productivity and staff capability MHS Business Unit:- Key actions: Creation of psycho education groups for IAPT services and psychology Improve uptake of first appointment by use of text reminders. Delivery risk- failure to improve update if texting not successful, mitigation by early evaluation of success and consideration of other approaches that could be introduced) Increase flexibility of opening times Work with commissioners to seek more funding for IAPT services How progress will be measured: MHS Business Unit:- IAPT targets Percentage of service users requiring urgent assessment that has been completed within 72 hours. Potential delivery risk- no further funding available from commissioners, mitigation, consider alternative approach within resource SWECS Business Unit:- Key actions Reduce time to offer of appointment to 6 weeks for Paediatric speech and language services and community paediatric services. SWECS Business Unit:- 18 week performance targets, specifically 6 weeks from time of referral to offer of appointments Potential delivery risk- service unable to deliver 18 weeks due to inability to manage demand through current capacity. Mitigation- maximise capacity and ensure careful monitoring of waiting times and feedback to service. NELCS Business Unit:- Do Not Attend (DNA) reduction plans in areas where waiting lists are unacceptable Potential risk DNA approach does not deliver reduction in waiting times Mitigation-early evaluation of DNA approach to ensure success. NELCS Business Unit:- 18 week performance targets captured and recorded through performance forums Monitor themes of complaints ( 13/14, 14/15) Discuss at Service User Groups and Patient & Public Engagement Forums

11 Quality domain: Quality and Clinical Effectiveness Improved clinical care (Quality account priority) Improve service quality, productivity and staff capability MHS Business Unit:- Key actions: Acute care pathway redesign Increasing staffing resource of Home Treatment Teams (HTT s) Close working with local authorities to ensure resource is available in the community via social care and housing for service users to avoid delayed transfer of care (DTOC). Robust use of CPA to enhance early discharge and reduced DTOC How progress will be measured: MHS Business Unit:- % of admissions to acute ward that were gate kept % of service users recovered following IAPT/psychological therapies ALOS for in-patients (13/14, 14/15) % of adults/older adults with delayed transfer of care (13/14, 14/15) Monitoring admission rates, (13/14, 14/15) Potential delivery risk acute pathway proposal not supported by key stakeholders, mitigation includes robust communication and engagement plan SWECS Business Unit:- SWECS Business Unit:- Key actions: To implement the Safety Thermometer across 4 key harm areas: pressure ulcers, falls, VTE risk assessments and catheter related UTI s. Improve continence assessment, education, training and support. Potential delivery risk- poor update of training, mitigated through clear communication to managers of expectations for their teams and monitoring of update via training department to identify any issues Number of avoidable MRSA bacteraemia and clostridium difficle cases ( 13/14, 14/15) Number of falls from intermediate care bed areas ( 13/14, 14/15) Number of avoidable and acquired grade 3 and above pressure ulcers (in-patient and community) (13/14, 14/15) Repeat incontinence audit Number of attendances at continence clinics, assessment times and quality of life scores NELCS Business Unit:- NELCS Business Unit:- Key actions: Falls action plan Serious incident action plan Falls strategy Falls audit Patients to receive falls risk assessments on admission to inpatient units Number of falls in intermediate care bed areas (13/14, 14/15) Number of avoidable and acquired grade 3 and above pressure ulcers (in-patient community) ( 13/14, 14/15) Potential delivery risk - falls risk assessments not carried out by all teams consistently. Mitigated through identification of Trust lead role, clear communication, training and frequent monitoring of update.

12 NELCS CQUIN PRIORITIES Smoking Cessation Patient Safety Thermometer Dementia Screening Improving quality and maintaining financial balance Development of plan for delivery of each CQUIN. Potential risk - failure to deliver CQUIN target will impact on associated income being secured. Mitigated through monthly monitoring at business unit performance meetings. By end of quarter implementation plan in place and monthly monitoring through business unit performance meetings reviewing progress. Quarter all CQUINs delivered to target MHS CQUIN PRIORITIES Dementia NHS Safety Thermometer Smoking Cessation Physical Health Recovery Payment by Results (PbR) Improving quality and maintaining financial balance Development of plan to ensure delivery of CQUIN Potential risk - failure to deliver CQUIN target will impact on associated income being secured. Mitigated through monthly monitoring at business unit performance meetings By end of quarter one 2012 implementation plan in place and monthly monitoring through business unit performance meetings reviewing progress Quarter all CQUINs delivered to target SWECS CQUIN PRIORITIES Venothrombosis Embolism (VTE) NHS Safety Thermometer Patient Experience - Net Promoter Equipment Dementia Making Every Contact Count Admission avoidance Frail elderly Improving quality and maintaining financial balance Development of plan to ensure delivery of CQUIN Potential risk failure to deliver CQUIN target will impact on associated income being secured. Mitigated through monthly monitoring at business unit performance meetings By end of quarter implementation plan in place and monthly monitoring through business unit performance meetings Quarter all CQUINs delivered to target Financial Strategy E. The Trust s financial strategy and goals over the next three years: The Trust has had a successful financial and performance year in 2011/12, generating a surplus in excess of plan and exceeding its cash target at year end. Throughout the year NELFT retained a minimum rating of 4, in-line with its plan. The FT also achieved a green rating on its governance targets at Q4 with Monitor, again in line with the plan. The rating had been amber-red briefly during the year due to CQC concerns raised following an inspection of Moore Ward but the CQC lifted these concerns following implementation of improvement plans by the Trust. The 11/12 summary results produced an EBITDA position of 14.5m (5.4%), Operating Surplus of 6.3m (2.3%) and net surplus of 2.9m (1.1%). There were three impairments made during the year - for the Mascalls Park site ( 3m), the Hedgcock Centre ( 2.3m) and for the Becontree Day Centre ( 0.4m). Before allowing for the impairments our net surplus achieved was 8.6m (3.2%). All of these outcomes meant that as a Trust we were able to record a strong FRR of 4 (4.3).

13 The Trust generated a surplus which was 3.6m above its plan. The extra surplus related to extra income for CHS and MHS not offset by higher costs, and lower than expected costs in Mental Health primarily due to savings on Individual Service Agreement budgets and community mental health team vacancies, and vacancies in community health services. This surplus and the associated cash is available to support future capital plans and manage financial risks. At March 2011 the Trust had a cash balance of 30.7m, above plan due to the previously mentioned higher than forecast surplus and increase to NHS creditors. This is expected to fall over the next year as creditors return to more normal levels. Under the terms of our authorisation as an FT we maintain a working capital facility (committed overdraft option - WCF) of 17.2m with Lloyds TSB. This was not utilised in 2011/12. The Trust s strategy is to maintain a minimum Financial Risk Rating of 3 in each of the next three years, ensuring strong liquidity and underlying financial performance to support the clinical priorities of the Trust and to generate resources to support our estates strategy. The Trust understands that effective and responsive clinical services can only be delivered where financial performance is strong as the impact of recovering poor financial positions on frontline services is significant. The Trust operates in a very challenged set of health economies. In North East London and the City the four local CCG s are seeking 15m of extra efficiencies to produce financial balance in 20 and have challenging QIPP targets for 13/14 and 14/15. Long standing financial problems with local acute providers, particularly Barking Havering and Redbridge University Hospitals Trust (BHRUT) continue to consume all growth funding year on year for CCGs, meaning investment in NELFT s non-tariff services community and mental health remains at risk when plans to reduce spending in acute care or elsewhere cannot be achieved. In SW Essex a substantial financial recovery plan implemented in 11/12 appears to have established a more sustainable funding position but acute cost pressures also exist from Basildon and Thurrock Hospital (BTUH) and others. To manage these external risks and internal cost pressures e.g. pay, drugs costs, non-pay etc. - the Trust plans to set financial targets for each of its three business units SWECS, MHS and NELCS based on a target 2% surplus in each year before allowing for reserves. Depending on the position of commissioners this is likely to require cost improvements of between 6-7% a year for each business unit. The Trust has a policy of not planning to cross subsidise between business units. Business units have devolved financial responsibilities and are charged with developing long term CIP targets engaging with senior staff and other stakeholders. CIPs are required to be specific in the first year and identified to the level of themes for subsequent years. The Trust also seeks to maximise efficiencies from corporate support functions which are now largely centralised, helping to reduce the impact of CIPs on frontline care. The Trust has progressed a strategy of seeking to acquire self-financing new business opportunities over the last few years, successfully acquiring SW Essex and the former ONEL Services in 2011/12. Although there are unlikely to be transactions of the same scale going forward the Trust will seek further such local opportunities where they can be seen to generate a return and defray corporate costs and help to manage risk. The Trust s income derives primarily from block contracts for MHS and CHS care, but this is likely to change as moves to implement first mental health and then community tariffs develop. The national timeline for MHS tariff may slip from 2013/14 but locally CCG s are keen to develop shadow prices and a similar process is likely in CHS. The Trust will seek to minimize risk from this process through effective data capture both clinical and financial and by aligning income streams to budget management to ensure the Trust understands its pattern of contributions by service. The plan for gives an FRR of 3, down from 4 in 2011/12. Although the uncapped FRR would be a 4 (3.6 rounded up), with Monitors test, if an individual component of the FRR is a 2 then an FT cannot achieve an overall rating above 3 and is therefore capped. Due to the EBITDA falling below 5% to 3.7% in, NELFT are in this position. There are two issues with this: The Trust pays rent to PCTs on CHS assets rather than pay capital charges. Although this has no effect on surplus, it does deflate EBITDA as operating leases are above the line in calculating EBITDA when capital charges are not. The acquisition of NELCS and SWECS during 2011/12 has led to lower overall surplus margins, mostly because NELCS plan for only reflects a 1% surplus target due to the financial risks from that transaction.

14 In order to achieve a sufficient EBITDA to keep an FRR of 4, an extra 2m of CIP would be required above the plan, and, given the strong liquidity position of the Trust such additional CIP is not considered appropriate. The planned surplus in 20 is forecast at 5.5m, equivalent to the plan for 2011/12, albeit on a higher turnover ( 309m compared to 235m pre-onelcs). All business units are planning to deliver between 1-2% of surplus. As agreed by the Board, ONELCS has agreed a target of 1% as a transition to a target of 2% in 2013/14, from break even in 2011/12. The surplus assumes utilization of recurrent reserves of 5.9m. An audit trail of income and expenditure from 2011/12 actual to 2014/15 plan is summarized as follows: 13/14 14/15 m m m b/f surplus income deflator (5.5) (13.5) (12.4) decommissioning (4.4) generic cost (3.2) (4.5) (4.3) exceptional item (inc depn, impairment) 5.4 (1.6) (0.8) Service development cost pressures (2.8) (1.6) (1.6) Asset transfer risk mitigation (2.5) agency reduction 1.4 CIP c/f surplus In 20 the internal cost pressures funded include MHS drugs ( 0.5m) to reflect 11/12 outturn and 1.2m of non-recurrent income / shortfalls in surplus in ONELCS. The other income losses relate to MHS and cover Essex inpatient CAMHS and disinvestment by LB Redbridge proposed in the Tier 3 CAMHS service. It can be noted that the 2011/12 actual position is 8.6m gross of impairments, so this offers some flexibility in meeting CIP targets where these savings are recurrent. Business Units have reviewed these in setting CIP plans. The future years plans are based upon the income and expenditure assumptions as mentioned at Appendix 3a and at 3g but the key drivers are: Income deflation / decommissioning between 4% and 5% for CHs and MHS Generic costs including 1% pay award, non-pay inflation and other cost pressures Exceptional items of impairment improvement and CHS asset transfers Service developments assumed at cost neutral CIP requirements of 15.7m, 18.3m and 18.4m in each of the plan years The plan FRR s for the three year forecast period are expected to slightly improve from a plan weighted average of 3.6 (capped to a 3) through to an uncapped 4.1 at 14/15. This improvement is predicated on the achievement of our CIP and decommissioning targets during this period feeding into an improved surplus margin and therefore underlying improvement to our financial performance moving the Trusts EBITDA from 3.7 to 5 over this time. Cash balances of 28.5m, 30.9m and 33.2m are forecast at March 2013, 2014 and 2015 respectively. Working capital is expected to reflect improved PCT/Trust creditor collection rates, although this has not so far been the case in 2011/12. The Hedgecock Centre is assumed to be sold by Q3 20. Mascalls

15 Park is forecast to be sold by Q4 in 2013/14 and Stonelea by Q3 of 2014/15, both subject to final planning consent. The 2013/14 cash plan includes a further EBITDA of 13.1m less capital expenditure of 7.4m, to include 4.4m for Phase 2 which will be subject to OBCs and FBCs before works start. The Department of Health have confirmed that PCT assets transferring to FT s where community services are provided will not now happen until April 2013, so will not impact on 20 the assumed income and costs are incorporated from 13/14 onwards. The cash spend on transferred CHS assets in included at net book value which we expect to receive PDC adjustment for. The Trust s working capital facility of 17.2m is projected not to be needed over the three year planning period although it will require extension in June Downside cash risks on EBITDA over the period may reduce cash balances, as may any decision taken by the Board later in to review the current financing of the PFI scheme on Chapters House/Barley Court. Leadership and Organisational Development F. The Trust s approach to ensuring effective leadership and adequate management processes and structures over the next three years is: Leadership and Organisational Development The Trust s approach to ensuring effective leadership and adequate management processes and structures over the next three years is: Board Membership As part of our on-going review of capacity and effectiveness the Board took a decision to appoint an additional last year. This decision was directly related to the need to expand our capability and capacity to embrace community health services as part of our diversifying business portfolio. This appointment has greatly added to our ability at Board level and enhanced our knowledge and functioning in our new areas of operation. The previous Medical retired in May The next generation of change will likely see our portfolio expand into acute care and in preparation for this we are now seeking to appoint a new Medical. Our structure of Business Units has allowed each of them to become more autonomous and for example the medical director in the Mental Health Business Unit effectively relieves the existing corporate obligation to have a psychiatrist in the executive Medical post. This process is being replicated across the other business units. In considering the appointment of a new Medical we have sought to engage high profile candidates that will have a higher level of credibility with acute and primary care. We expect to complete this appointment process before the end of May Non- Membership We have a strong and experienced group of Non- s but all are in their second term and over the next 5 years all would have served 10 years on the Board. In line with best practice we are now beginning the process of refreshing the Non- team and an independent review of the skills needed in our Non- s is now being carried out to inform our future recruitment. Board Assessment As part of our post implementation planning following our major acquisitions we undertook an exercise in reviewing management capacity at a senior level. This work proved useful and it is being repeated currently on a wider scale to inform actions in the near future. We are also currently undertaking an independent review of Board effectiveness. This work is being carried out by an independent consultant and will likely be reported back to the Board in June this year. This will then inform an action plan for the Board in the time ahead. Board Development The organisation maintains a programme of Board workshops specifically designed to keep members up to date both with internal issues and national change.

16 All Board members are subject to on-going review and development and this is formalised for executive directors in monthly review, objective setting and personal development plans. Several of the executive directors are working on academic programmes as part of their longer term development and succession in the organisation. Non-executive directors are also subject to review by the Chair and external workshops and conferences are deliberately used to support their development and they too contribute to the workshop programmes internally as well as influencing the topics covered as part of our development plans. Further considerations. The Board is currently reviewing with Governors how best to ensure that all Governors have a clear understanding of the governance structures which provide assurance to the Board about the clinical quality and safety of our services and the financial stability of the Trust. The Health and social Care Bill recently enacted puts further responsibility on Governors and the Board is keen to work with Governors to ensure they have the skills fulfil their role confidently and effectively. The Trust re-structured into three business units in 2011 to accommodate the acquisition of additional services. Each unit has distinct commissioning arrangements which will continue until March This structure will also enable assimilation of Redbridge Children s service and further community dentistry in Quarter 2 following successful tenders. Senior management appointments to manage this arrangement will be completed in Quarter 1 of 20. At that point Clinical Commissioning Groups are planned to become fully operational locally. In addition the Post Implementation Plan for the North East London Services business unit requires a transitional period operating as a distinct business entity whilst a major service transformation exercise is undertaken to be concluded at the same time. Therefore, at the end of 2012 the Trust will review these business and management structures to ensure alignment to new commissioning arrangements, and to maximise leadership capacity within anticipated cost constraints. Factors which will be material to the business unit structure and management arrangements decided will include alignment with commissioners, projected management efficiency, sharing leadership expertise across services, and anticipated future acquisition of services arising from implementation of the commissioner sponsored Health for North East London programme. During the three year period of this forward plan the Trust will be investing in management and leadership development to increase capability. In particular, skills in change management and working/negotiating effectively with external agencies and partners have been highlighted as priorities in view of the service transformation and productivity challenges identified during this period. This builds on successful development programmes commissioned and run throughout 2011/12 in collaboration with London South Bank University. Support in meeting these development needs will again be sourced externally. Fundamental management processes such as Appraisal and Personal Development Planning have been reviewed, and the Trust is rolling out a new Performance Appraisal policy to all staff in 20. This will require all managers to score staff performance using objective information, and to incorporate specific Trust objectives and priorities into each employee s objectives. The full benefits of these changes will be realised in 2013/14. The Trust has joined a collaborative learning programme (Leading Large Scale Change Support Programme) which will be joint learning by clinical leaders and senior managers with the main acute Trust in delivering new service models across organisational boundaries Other Strategic and Operational plans The Trust s other strategic and operational plans over the next three years: Within the overall Trust strategy there are a number of other strategic and operational plans which will support delivery of each of our Corporate Objectives, these sub-objectives are outlined below Corporate Objectives

17 Improve service quality & productivity (sub objectives) Implementation of framework for care (clinical strategy) Priorities Target Lead Delivery Risk & Mitigation Timescale Research & Development ( R&D) R&D evidence a system that is capable of responding to service evaluation across the trust. Medical Inability to deliver a robust system- this will be mitigated through building in a robust evaluation phase. required: within current resource Clinical engagement in CIP development To achieve an audit outcome of substantial assurance on the engagement of clinicians in CIP planning Medical & Chief Nurse & for MH Inability to demonstrate clinical engagement in CIP planningmitigated through recording and minuting meetings where CIPs are shared and agreed. required: No additional Patient satisfaction Implement data capture software for clinical audit and patient experience required: any additional software costs to be determined. Chief Nurse & for MH Risk of inability to join up all key elements of clinical audit and patient experience across all three business units. Mitigated through robust project planning and building in evaluation phase. Review progress Implementation completed 13/14 Clinical Audit 100% increase in number of IA days spent auditing clinical issues No risks identified Audits agreed required: within current resource Clinical audit plan developed

18 Psychological Therapies Fully implement the recommendations from the new Psychological Therapies review required: within current resource Chief Nurse & for MHS Risk of key staff not fully engaging in implementation phase. Mitigated through supervision and appraisal process. Psychodynamic Psychotherapy Consultation complete Review progress against implementation of recommendations Emergency Planning Receive substantial assurance from audit at similar point in time in required: within resource Services & Potential risk is the level of buy- in from both the business units and the corporate services. Mitigation via additional level of investment on a temporary basis to support service engagement. Auditors to undertake work by end of 05/12 Any recommendations arising to be implemented by end of 10/12 Quality Accounts Completion and submission of the annual quality accounts Chief Nurse & for MH Quality accounts on track no risks identified required: within current resource Dementia Strategy To scope current position against Dementia Strategy and identify gaps required: support from in house transformation team. Project plan in place. Chief Nurse & for MH Dementia project on track against plan, no risk identified. Scoping exercise completed by end of Qtr 1, Organisational action plan in place and progressed by end of Qtr 4 Implement new risk systems and processes across organisation To improve quality and provide assurance to Board that robust risk management is in place across the organisation. Chief Nurse & for MH Potential risk- risk approach not embedded at all levels within organisation. Mitigated with robust risk strategy approach and training sessions across all business units. Risk system implemented required: purchase costs of new risk system TBD Improve service quality & productivity (sub objectives) Implementation of mobile working strategy

19 To take forward the mobile working strategy (aiming to increase the number of staff with access to mobile working technology) to improve productivity To develop a business case for consideration and approval by end of Qtr1 to establish the number of new accessible mobile working units to be funded and purchased during. Implementation to be part of mobile working project Services & Potential risk- mobile working does not achieve the increase in productivity expected. Mitigated through transformation workshop to support clinicians with working differently. Business case to EMT end of Qtr 1 (AD IM& T) Review progress November 2012 On-going expansion of use of mobile technology 12/15 required: mobile equipment costs TBD following production of business case. Support for implementation from in house transformation team Implementation plan to be developed following agreement of business case. Deliver service transformation and improve local environments (sub-objectives) Acute care pathway reconfiguration Progressing the Quest4Excellence transformation programme Establish agreement and complete a public consultation for the closure of the MH beds at Nasebury Court required: within current resource and support from in house transformation team. Project plan in place. Chief Nurse & for MH Risk delay with implementation if key stakeholders do not support. This may impact on CIP target. Mitigated through robust communication/ engagement strategy and consideration of contingency plan for associated CIP. Review progress Brentwood Hospital Agree plan for BCH with commissioners and implement changes in accordance with Services & Potential risk- additional service capacity not taken up by GPs, mitigated through robust marketing Review progress

20 agreement /communication strategy required: within current resource. Implementation plan to be developed Rapid assessment, interface and discharge (RAID) Agree plan for RAID investment and development within NEL commissioners and agree outcomes for performance purposes Chief Nurse & for MH Risk- no new investment secured from commissioners. Mitigation to explore alternative delivery model with remodelling current resources. Review progress required: TBC following discussions with commissioners. Single Point of Access (SPA) Review current SPA services across organisation and agree future model. required: within current resource. Project plan in place to deliver options appraisal. Services & Risk- new SPA model does not delivery local requirements. Mitigated with representative of each business unit involved in options appraisal and clear service evaluation criteria. Options paper to EMT EU Telehealth Project (3 year project) To progress project against plan required: 50% funding from EU; remainder within current resource and support from transformation team. Project plan in place. Services & Risk- unable to recruit required numbers of patients. Mitigated by recruiting from both community business units. 12/15 research project Beds Redesign (NELCS) To review and redesign in line with ONEL service spec and take account of H4NEL priorities required: within current resource and from transformation team. Implementation plan to be developed. Services & Risk- reduction in bed base will require consistent delivery of ALOS targets. Mitigation through transformation project and reviewing compliance to admission criteria. Review progress (July) QIPP-Frail To redesign services working Risk- reputational risk if service redesign delayed. Review progress