Delivering in a challenging environment

Transcription

1 Trust Development Authority Delivering in a challenging environment Refreshed plans for 2015/16 Planning Guidance for NHS Trust Boards December 2014

2 Delivering in a challenging environment: refreshed plans for 2015/16 Contents Introduction 3 A challenging year ahead 4 Supporting NHS Trusts to meet the challenges 8 Improving demand and capacity planning 10 Workforce development 13 A greater focus on support and development in the year ahead 14 (2014) Any enquiries regarding this publication should be sent to: Southside 105 Victoria Street London SW1E 6QT England 2

3 Introduction The NHS is at a critical juncture. The pressure of significant and sustained increases in demand for some services coupled with the strain on public sector finances is creating real and substantial challenges for local NHS leaders as they strive not just to deliver for today, but to create a strong platform on which they can transform services for tomorrow. Delivering in a Challenging Environment: refreshed plans for 2015/16 aims to support NHS Trust Boards to provide a refreshed and updated plan for the year ahead, which, while building on their five year projections and plans, will take into account changes that have occurred either locally or nationally during the year. The document sets out the new requirements on providers that have been devised either by commissioners or regulators since the previous plans were submitted. It should be read in conjunction with The Forward View into Action, which, for the first time since the NHS reforms, sets out in one place the joint high-level ambitions and system priorities for commissioners and providers. There are reasons to be optimistic about the year ahead including the welcome announcement of additional resources set out in the Chancellor s Autumn Statement and closer working between national partners signalled through the Forward View. But there are also very real challenges for providers in 2015/16 which will require all NHS Trusts to approach planning for this year in a more rigorous way than before. Addressing the risks early and creating joint local mitigation plans will create the platform not only for NHS Trust Boards to deliver against their aspirations for the year ahead but also the strong foundations needed in local health economies to transform care in the future. Planning Guidance for NHS Trust Boards 3

4 Delivering in a challenging environment: refreshed plans for 2015/16 A challenging year ahead The proposed business rules for 2015/16, as set out in Monitor and NHS England s national tariff consultation and NHS England s standard contract consultation, have the potential to make balancing quality, delivery and finance tougher for providers in 2015/16 than it has been in the year gone by. This demonstrates the pressures facing decision-makers both nationally and locally and that there are no easy choices in the current environment. Proposals that NHS Trust Boards will need to be particularly mindful of when agreeing their plan include: n The introduction of a default 50:50 gain and loss sharing price setting rule for acute prescribed specialist services activity above 2014/15 planned levels; n Changes to the standard contract which introduce higher penalties for non-delivery of NHS Constitutional standards and information reporting failures together with a shift to make all sanctions automatic in future; n The ambition of making significant progress toward implementing 24/7 working in the absence of further investment; and n Delivering further efficiency gains of 3.8% after the sustained period of a 4% efficiency factor. It is welcome that the NHS has received an additional 1.83 billion of Government investment with an additional 150 million of reallocated NHS England funding to help alleviate those pressures in 2015/16. However, it is also clear that this means that there will be no additional in-year funding such as the funding to support delivery of referral to treatment operational standards and system resilience which was made available during the current financial year as this is now included in commissioner baselines and should be agreed as part of the contractual process. It is therefore more critical now than in previous years that the plans providers submit and sign off are as strong as they can be and are underpinned by clear and rigorous demand and capacity planning. From the provider side, this must set out in absolute terms what can be delivered within the commissioning envelope and be supported by a commissioning plan which sets out a more rigorous approach to demand management in the year ahead. Underpinning business rules Notwithstanding these additional pressures, NHS Trust Boards will have to produce a clear plan which sets out how they will achieve the delivery of all national standards during 2015/16 as well as demonstrating a robust and credible plan for financial sustainability. Accordingly, where income for particular services is falling through stricter business rules or tariff movements or providers feel they need to invest more in the cost of particular services that is not matched by increased revenue income, NHS Trust Boards should consider whether they can afford to provide these services without impacting on service quality. The balance between financial discipline, service quality and safety and levels of activity must be maintained. A number of Trusts, particularly those that provide acute services, will end 2014/15 in a deficit financial position. This will be of significant concern to the Boards of those organisations and the NHS Trust Development Authority (NHS TDA) as it calls into question the sustainability of a number of the services provided by these organisations. In some instances it will be clear that a Trust is not sustainable in its current form and in these circumstances the Trust, with the NHS TDA, will be considering the best option to secure an alternative future for the services they provide. However, under any circumstance it remains a key responsibility of the Boards of all NHS Trusts in actual or underlying deficit to progress financial recovery at a challenging but manageable pace. NHS Trust Boards that cannot demonstrate full financial recovery within three years, i.e. by 2018/19, can expect specific conversations with the NHS TDA regarding their options for service sustainability. 4

5 It is more critical now than in previous years that the plans providers submit and sign off are as strong as they can be and are underpinned by clear and rigorous demand and capacity planning. challenges Planning Guidance for NHS Trust Boards 5

6 Delivering in a challenging environment: refreshed plans for 2015/16 A challenging year ahead Accordingly all NHS Trusts reporting deficits in 2014/15 are expected to produce plans that demonstrate marked improvement in financial performance in 2015/16. As part of this plan, NHS Trust Boards will be expected to take into account the following: 7 Day Working Commissioners are asking all providers of acute care to make further progress in 2015/16 to implement at least 5 of the 10 clinical standards for seven day working, when doing so is affordable within resources available. Updated service development and improvement plans for seven day working should include reporting based on the NHSIQ self-assessment tool. Specialised Commissioning The 2015/16 National Tariff consultation proposes a national variation to tariff and a local pricing rule whereby all acute, prescribed specialised services will operate under a 50:50 default gain loss share on the 2014/15 contract value. This change in pricing policy represents a significant transfer of risk and financial pressure from the commissioning sector to the providers of specialised services. The NHS TDA expects NHS Trusts to work with commissioners to understand the impact of this approach on the sustainability and safety of services. Better Care Fund CCGs and Councils submitted Better Care Fund plans via the Health and Wellbeing Boards to NHSE in September These plans will need to be kept under review in light of actual and forecast performance for 2014/15. During the contracting round for 2015/16 NHS Trusts will need assurance that the elements of the Better Care Fund plans of CCGs and Councils that impact them include a clear rationale for the scale and impact of changes, have been subject to clinical engagement and contain measurable objectives and details of revised volumes of care to be delivered at a granular level. In-year allocations For a number of years the NHS has received in-year allocations above that included in the NHS mandate at the start of the financial year. Additional resources of 1.98bn in 2015/16 were announced in the 2014 Autumn Statement. This investment in the NHS provides certainty of funding in 2015/16 including areas such as system resilience that would previously have been resourced from in-year allocations and as a result of this no further in-year allocations should be anticipated. CQUIN Commissioners must offer each provider, through CQUIN, the opportunity to earn up to 2.5% of its annual contract value (excluding drugs, devices and other items funded on a pass-through basis). The aim of CQUIN is to incentivise providers to deliver improvements in service quality and outcomes for patients, going beyond the core requirements of normal good practice set out in the Contract. The 2015/16 CQUIN scheme will feature four national indicators, with an even balance between physical and mental health. There will also be a new national CQUIN theme on improving urgent and emergency care across local health communities, with commissioners able to select indicators locally from a menu of options. NHS England is publishing separate, detailed guidance on the 2015/16 CQUIN scheme. It is clear that the combination of these changes will make planning the balance between delivering service transformation, delivering cost improvements, achieving core national standards and focusing on financial recovery harder next year than it has been previously. Despite this, we expect that all NHS Trust Boards will proceed to plan on the basis of achieving this balance and where they identify risks that they cannot mitigate solely by themselves they should work with NHS TDA Delivery and Development Teams to confirm the actions necessary to address those risks. 6

7 The provider sector as a whole, in addressing these risks, is going to require additional support and development ranging from how to better plan for workforce challenges through to how to improve demand and capacity planning. In addition to this, there are a limited number of changes that have occurred to last year s priorities that NHS Trusts will have to address. These are: n End of life care The Leadership Alliance for the Care of Dying People published One Chance to Get it Right in June This sets out the approach to caring for dying people that health and care organisations should adopt. Over the next year the NHS TDA will draw on the learning so far around local implementation of this strategy and will work with organisations to support delivery of the recommendations, including all patients having a personalised care plan for end of life care and regularly reviewing the quality of end of life care through audits and complaints from bereaved friends and family. n Enhancing access to Mental Health care Achieving Better Access to Mental Health Services by 2020, published by the Department of Health and NHS England, sets out expectations for enhancing access to mental health services in the year ahead. This includes the need to prepare for and implement new access standards during 2015/16 and achieve these on an ongoing basis from 1 April 2016, such as: 75% of people referred to the Improved Access to Psychological Therapies programme will be treated within 6 weeks of referral, and 95% will be treated within 18 weeks of referral. More than 50% of people experiencing a first episode of psychosis will be treated with a NICE approved care package within two weeks of referral. Between January and March 2015, the NHS TDA will, through the planning process, work directly with every NHS Trust that provides mental health services to support them in preparing for the introduction of the new standards. n Complaints handling Listening and responding to patient complaints has been a key theme of the last few months with a number of reports, from the CQC s Complaints Matter report to the Parliamentary Health Service Ombudsman s recently published vision My expectations for raising concerns and complaints. We are committed to supporting Trusts to make improvements in this area in the context of this new vision and the CQC s approach to inspection learning from what works and also working with the PHSO and the CQC. There are also significant national reports due out in the coming months that we will collectively need to consider the implications of, including: the Department of Health s One year on report following Hard Truths, the Government s response to the Francis Inquiry; the Freedom to Speak Up review, led by Sir Robert Francis QC into creating an open and honest reporting culture in the NHS; and guidance from NHS England, expected during 2015, arising from the Urgent and Emergency Care Review. As part of preparing for and responding to that agenda, organisations should ensure they participate in local System Resilience Groups (SRGs) and wider urgent and emergency care networks, formed when SRGs come together to consider more strategic issues over a wider geographic area. Planning Guidance for NHS Trust Boards 7

8 Delivering in a challenging environment: refreshed plans for 2015/16 Supporting NHS Trusts to meet the challenges To support and assist NHS Trusts in developing robust financial plans, the NHS TDA will provide a number of practical tools. The benchmarking of acute, mental health and community services using reference costs was successfully piloted from early The feedback received from NHS Trusts on the pilot was invaluable in amending and updating the reference cost benchmarking tool and the latest version based on 2013/14 reference cost data was released to NHS Trusts at the end of November The package of support also includes a pre-recorded webinar that takes users through the benchmarking tool and explains the functionality available. Triangulation of the finance, activity and workforce plans is critical to demonstrating that the NHS Trust has a credible, robust set of actions planned for the coming year. In order to support NHS Trusts in their review of plans prior to submission, the NHS TDA have designed a pilot spreadsheet tool which provides dashboard summaries for each of the finance, activity and workforce plans and performs a series of triangulation tests to identify how well the finance, activity and workforce returns are aligned. Improved planning templates and guidance The financial plan data collection has been reviewed in the light of the previous year s plan collections and has been improved to assist NHS Trusts in navigating the forms with more embedded guidance and commentary included with the intention of improving data quality and ensuring consistency of reporting. Dispute resolution process It is a major failing of a health economy where parties do not manage to reach agreement prior to the start of the financial year and we therefore expect that robust, good value contracts are signed by the contract signature deadline of 11 March To support this process, the NHS TDA, NHS England and Monitor have developed a joint dispute resolution process, including a set of overarching principles that it will be mandatory for all commissioners and NHS Trusts to adhere to. These overarching principles will helpfully assist providers and commissioners on specific items including QIPP and the Better Care Fund plans. Plan assurance Teams within the NHS TDA also have access to the same charts and visualisations as part of a standard set of information intended to assist in the review of NHS Trust plans. Whilst the triangulation tests are a desk top assessment of reasonableness, they provide a high level indication of where plans may be poorly aligned internally. To help NHS Trusts navigate this new tool, a pre-recorded webinar is available to support the use of this pilot spreadsheet. 8

9 Triangulation of the finance, activity and workforce plans is critical to demonstrating that the NHS Trust has a credible, robust set of actions planned for the coming year. support Planning Guidance for NHS Trust Boards 9

10 Delivering in a challenging environment: refreshed plans for 2015/16 Improving demand and capacity planning Referrals to hospitals in England have been accelerating at a rate higher than demographic pressures. There has been a 4% increase in activity in 2014/15 when compared to the previous year but this trend is significantly above the planned levels agreed between commissioners and providers, with GP referrals and non-elective activity running at 12% and 9% above planned levels. This unplanned growth in demand for care in a hospital setting has been difficult to respond to in a safe and affordable way. Going forward it is therefore essential that providers and commissioners work together to develop accurate demand and capacity plans that both fulfil the planning requirements and ensure patients have access to safe and sustainable services. Throughout 2015/16, the NHS TDA will take a robust approach with NHS Trust Boards that fail to adhere to the plans they submit for the year ahead as further deterioration in quality, performance or finance could have a significant and lasting impact on NHS Trusts ability to deliver sustainable, high quality care. During this current financial year, some NHS Trust Boards have responded to additional pressures by allowing key national standards to slip below a level that is acceptable to patients and/or by incurring expenditure that they have no funding for, resulting in deficit and the need for cash support to fund their operations. This, in part, has been down to poor contracting arrangements at the beginning of the year, or a failure either on the part of the provider or the commissioner to agree and adhere to a meaningful demand and capacity plan that builds in sufficient resilience to variation in demand. However, it has also been a result of poor delivery of planned cost improvements and/or weakening in best standards of financial governance and control. This cannot continue. In preparation for the challenges of the year ahead, between January and March 2015 the NHS TDA will be working more closely with NHS Trust Boards than in previous years to provide appropriate support to assist the development of robust demand and capacity plans and to ensure that contracts reflect the right approach to risk sharing between providers and commissioners. In January, the NHS TDA will ensure NHS Trusts have a Guide to Best Practice on Capacity and Demand Planning which will support NHS Trust Boards to approach this year s planning round in a more robust manner than in previous years. In addition, during January, the NHS TDA will hold a series of four regional workshops, supported by the National Intensive Support Teams, targeted at chief operating officers and senior operational managers, to support frontline teams in generating fit-for-purpose plans for the year ahead. The stricter rules around the application of fines, coupled with the introduction of a default 50:50 gain and loss sharing price setting rule for acute specialised services and the clear signal that additional resources will not be made available in-year during 2015/16, mean it is essential that all NHS Trust Boards are clear on what they are signing up to deliver in their contracts, underpinned by strong demand and capacity plans. All NHS Trust Boards will be expected to fully participate in the additional support provided between January and March to ensure contracts are as strong as they can be for 2015/16. Contracts will need to be clear on the upper limits of additional unplanned capacity that will be allowed before local mitigating action is taken and providers will be expected to attain commissioner support on this. Failure to identify clear capacity limits may expose providers to significant risk either to the quality of care they are able to provide across their organisation or to having to spend resources they have not been allocated, neither of which NHS Trust Boards can accept. The balance between quality, delivery and sustainability has to be central to every NHS Trust Board s plan for 2015/16 and whilst the safety of services cannot under any circumstances be compromised, the NHS TDA will expect NHS Trust Boards to show a regard for each of these key areas. 10

11 The NHS TDA will be working more closely with NHS Trust Boards to support and assist the development of robust demand and capacity plans and to ensure that contracts reflect the right approach to risk sharing between providers and commissioners. planning Planning Guidance for NHS Trust Boards 11

12 Delivering high quality care, where safety comes first While providing services in a challenging environment can create risks around the quality of services a provider is able to deliver, it can also create a platform from which organisations can transform the way they provide care to become both more effective but also more efficient. Throughout the past year the quality of care delivered in NHS Trusts has come under the spotlight. The drive to ensure safe staffing levels, which has developed during the year, has identified risks in some NHS Trusts and the Chief Inspector of Hospitals regime has become established and is regularly identifying local quality challenges. During 2014/15, the NHS TDA Quality Directorate which brings together nursing, medical and broader clinical teams has focused on developing new ways to support frontline teams on issues ranging from workforce and recruitment through to healthcare associated infections and mortality. We expect all NHS Trust Boards over the coming year to make safety and building a safety culture a priority in order to improve patient care, boost staff engagement and satisfaction and save money. In doing so we would strongly encourage all NHS Trusts to join the national Sign up to Safety campaign in which there is dedicated support for organisations and, following their launch earlier this year, all Trusts should engage with local partners through the new Safety Collaboratives. We will continue to work closely with the campaign to support NHS Trusts who sign up to develop their safety improvement plans and to share good practice and learning. So far around 50% of NHS Trusts (45 organisations) have signed up and we urge others to join them in the coming year. Beyond that, throughout the year ahead, the NHS TDA Quality Team will continue to provide day-to-day support and advice on safety through our established work on: n Medicines optimisation providing tailored support to organisations, from development visits with our Chief Pharmacist or facilitated peer support to assistance with the preparation and response to CIH inspections as well as the roll out of the NHS TDA s Medicines Optimisation and Pharmaceutical Services Framework which allows Trusts to self-assess against a range of good practice on medicines management. n Infection prevention and control the NHS TDA s regional infection leads continue to work closely with organisations providing day-to-day advice and routine information on emerging issues, such as carbapenemase-producing Enterobacteriaceae and Ebola, linking in to key networks such as directors of infection prevention and control (DIPC) forums, or more hands on support visits to NHS Trusts, working in close collaboration with key partners such as CCGs, NHS England and Public Health England. n Mortality governance as well as individual support and advice for NHS Trusts to enhance their approach to mortality governance as part of the planning process, we are launching a regular forum for all providers to share good practice in this area in the New Year. Key to underpinning a strong safety culture is an effective system of quality governance, which is an important element of the journey to Foundation Trust status. With the benefit of additional capacity and capability in our regional quality teams, we will work more closely with organisations over the next year to provide support and challenge on Monitor s Quality Governance Framework in the context of the upcoming well-led framework working closely with Monitor and NHS Providers (formerly the Foundation Trust Network). 12

13 Workforce development The ability to undertake effective workforce planning and monitoring next year will be crucial. Throughout this year the environment around safe staffing has changed dramatically, with in-year pressures on provider organisations to attract, in particular, new nursing staff something which has led to greater reliance on agency staffing at premium rates and a number of NHS Trusts looking overseas for new staff. Some of this has contributed to the pay bill spend rising at a rate most NHS Trusts cannot afford or sustain. Throughout 2015/16, the environment will not get easier and the general pressure on the workforce demands will increase. The NHS TDA expects NHS Trusts to have a robust and affordable workforce plan to deliver safe services, triangulated with finance and activity plans, signed off by the Board and monitored closely in-year with a range of key performance metrics. The NHS TDA is committed to supporting organisations with this process, starting with the planning cycle but continuing into our oversight process throughout the year by: n ensuring our support and challenge on workforce is co-ordinated across the NHS TDA s workforce and finance teams to ensure a single view is provided. n the development of a triangulation tool to assist the planning process. NHS Trusts will be able to link their workforce, finance and activity planning returns through a single spreadsheet provided as part of the suite of financial planning materials that will allow NHS Trusts and the NHS TDA to perform a series of triangulation tests to identify how well the finance, activity and workforce plans are aligned. n the development of a benchmarking tool for NHS Trusts to assist in-year analysis of key workforce metrics against peer groups at Trust level. It will enable organisations to both track delivery of their plan in-year and to compare their performance across a range of workforce, finance, activity and quality metrics with their peers. This capability builds on and replaces the previous Workforce Assurance system and will be launched and accessible to all NHS Trusts by 31 March 2015 for use from the start of the new financial year. All NHS Trusts are expected to use this system and appropriate advice and support will be provided ahead of roll out. This will then form the basis of the monthly in-year conversations between the NHS TDA and NHS Trusts through established oversight mechanisms such as Integrated Delivery Meetings (IDM). n Enhancing day-to-day support on workforce issues. Starting in January, the NHS TDA will work with cohorts of NHS Trusts to support them to better manage workforce pressures through a series of events and workshops. These will be both sector specific, to acknowledge the particular challenges faced by different Trust types, but also across broader common themes such as getting the most out of the Electronic Staff Record system. Planning Guidance for NHS Trust Boards 13

14 Delivering in a challenging environment: refreshed plans for 2015/16 A greater focus on support and development in the year ahead The challenges facing NHS providers are greater today than at any time in recent history, yet the performance of some providers and the approving of organisations such as Royal United Hospitals Bath NHS Trust, Derbyshire Community Health Services NHS Trust and Bridgewater Community Healthcare NHS Trust to become Foundation Trusts show that success can be achieved even in the most difficult conditions. Even where some organisations have fallen below expected standards either in delivery or finance it is recognised that the efforts and leadership of local managers and clinicians to address problems has been essential to supporting a recovery plan. The development work that has been undertaken by the NHS TDA so far such as practical events and workshops, support to aspirant trust boards, day-to-day support on everything ranging from managing cash-flow through to infection control, professional leadership support and intensive support for organisations that have been placed into special measures has already helped a number of NHS Trusts to improve in key areas. However, during 2015/16 the NHS TDA will move its development and support activity onto a more formal footing, setting out a programme of work for the year ahead that will provide dedicated, longer-term support for NHS Trusts, targeting issues where improvement is most needed. During January and February 2015, regional Delivery and Development Teams will be working with leaders from every NHS Trust to confirm and challenge their development and improvement plans, from which the NHS TDA will develop a number of themed improvement opportunities aimed at cohorts of organisations with similar challenges, which will run during the course of the whole of the next financial year. Alongside this, the NHS TDA will publish a programme of activity to enhance professional leadership support and development, targeted at key professions ranging from finance to clinical and communications to nursing. This programme will provide on-going professional development and support for key leaders in local NHS trusts and will build on the work already developed for nurse leaders, medical leaders and communications leaders in NHS Trusts. For a small group of NHS Trusts the NHS TDA is developing a proposal to support them over the long-term by generating partnerships with worldleading organisations with a focus on creating the opportunity for NHS Trusts to transform their approach to reducing harm and waste. NHS Trust Boards will be invited to put themselves forward for these partnerships early in the new calendar year, with the partnerships being launched in the new financial year. 14

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