Appendix X: PEST and SWOT Analysis

Appendix X: PEST and SWOT Analysis

A. PEST ANALYSIS A.1 POLICY AND POLITICS A.1.1 Forces and drivers for change Guidance from the Royal College of Surgeons of England, the Royal College of Physicians of London, the British Association for Emergency Medicine, the Faculty of Accident & Emergency Medicine of the Royal College of Surgeons in England and the Academy of Medical Royal Colleges that: Emergency surgical services should be organised for a population of 450-500,000 The provision of comprehensive elective surgical care on a stand alone basis by a DGH is not sustainable and should be replaced by a network of hospitals serving populations of 500-600,000 The ideal unit for fully comprehensive medicine and surgery is a hospital or group of hospitals serving a population of 450-500,000 The lowest catchment population for district hospitals providing 24 hour children s services, 24 hour surgical services and maternity services as well as acute medicine and surgery is 250,000 local hospitals serving a population less than 250,000 are unlikely to be able to sustain 24 hour/emergency surgery or inpatient paediatrics or consultant led obstetrics and may have to operate a selected medical take There should be no single handed consultants in any major subspeciality Smaller A&E units seeing less than 40,000 new patients per annum should be supported where they are able to demonstrate their effectiveness, safety and quality and where they serve geographically isolated populations The above changes will be triggered by a lack of medical manpower following on from the introduction of the EWTD. West Midlands SHA has identified that paediatrics, maternity, A&E and emergency surgical services within the region are challenged (Investing for Health Chapter 6) DoH policy emphasising the shift towards greater levels of care being provided by primary and community care providers or in a community setting Growing recognition at national level that set against the advice of a range of professional bodies and DoH policy that traditional models for the organisation and management of local health economies are increasingly outdated and that central government has a role in brokering the necessary structural change DoH policy emphasising more aggressive management of chronic disease/long term conditions Roll out of Patient Choice Roll out of Practice Based Commissioning Page 1

Creation of competitive market for NHS funded healthcare (evidenced by four sets of overlapping changes: creation of a new regulatory framework; transfer of responsibility for service provision from government to Foundation Trusts and the granting of private sector providers equal status with FTs; reduction in the constraints on capacity (and hence competition) represented by a limited supply of medical staffing; empowerment of patients through Choose & Book and the introduction of a tariff based reimbursement system for providers) Entrance of private sector into market for NHS funded healthcare Establishment of Foundation Trusts and acquisition by FTs of NHS Trusts unable to demonstrate viability Increasing regulatory burden Policy differences between NHS England and NHS Wales Investment by the DoH in the development of world class commissioning Potential establishment of a Public Services Trust by Herefordshire PCT and Herefordshire Council Impact: HHT needs to adopt a strategy based on a clear recognition and understanding of the dogbone effect. This is the phenomenon whereby smaller secondary care providers lose services or referrals to larger secondary/tertiary providers with the necessary critical mass/able to meet increasingly stringent quality standards on the one hand and to primary and community care providers on the other. A number of services provided by HHT specifically A&E, obstetrics, paediatrics and emergency surgery are vulnerable. The management of the challenges posed by the dogbone effect and the vulnerability of core DGH services needs to be put in the context of the introduction of a market for NHS funded healthcare characterised by patient choice and competition between providers, of a recognition that changes to the traditional structures of healthcare economies are in some instances both necessary and desirable and of a new commissioning regime. HHT cannot expect to be shielded from the challenges facing it. Survival as an independent organisation is not guaranteed. The organisation needs to reinvent Page 2

itself and develop and implement a strategy which allows it to punch above its weight. A.1.2 ECONOMICS Forces and drivers for change: Reduced levels of NHS growth 2008/9 onwards Roll out of Payment By Results and reduced real terms income per HRG High costs of capital High costs of labour Reducing costs of some new technologies Increasing costs of drugs and therapeutics Increasing costs of litigation Impact: HHT needs to put in place systems, structures and processes to support cost containment and improved productivity Investments made in services or infrastructure need to provide the maximum return on investment. HHT needs to become smarter in the way it invests in new technologies The costs of poor quality (and the centrality of quality in the operation of the market) will force a more aggressive approach to the management of quality 1. SOCIETY Forces and drivers for change: Demography: an increase in the proportion of older people within the population, in the absolute numbers of older people and in the numbers living alone Page 3

Epidemiology: increased prevalence and incidence of obesity and diabetes Increased mobility Demand for local access to services in a rural area with a scattered population Increasing public expectations Immigration into Herefordshire by EU migrant workers Continuing problems in recruiting key staff Impact: HHT needs to develop an overarching model of care which recognises the unique combination of challenges posed by local demography and geography, a more demanding customer who is able to access other providers HHT needs to understand and respond to the needs and wants of migrant workers HHT needs to ensure that it is seen in the labour market as an attractive employer. Failure to attract mission critical staff (or failure of the education system to ensure an adequate supply of trainees) will potentially accelerate the dogbone effect A.1.3 TECHNOLOGY Forces and drivers for change: Increasing complexity of hospital care Increased levels of subspecialisation within the traditional taxonomy of secondary care services Changes in clinical practice: shorter lengths of stay; increased levels of day surgery Increased volumes of care traditionally provided by secondary care providers now provided by primary and community care providers Increased volumes of secondary care traditionally provided in an institutional setting Page 4

now provided in a community setting Increased volumes of hi tech secondary care now being referred to tertiary care providers Increased use of standard care protocols Introduction of new technologies (eg genetic technologies) resulting in therapeutic rather than surgical interventions, delivery if hi tech care in a lo tech setting Increased mobility/miniaturisation of diagnostic equipment Continuing advances in IT Impact: Alongside HR, technological change will potentially accelerate the dogbone effect. Technological change in this context includes both soft technologies (subspecialisation and changes in clinical practice) and hard technologies (new equipment). HHT needs to support the delivery of (demonstrable) high quality care through increased use of formal protocols and pathways New technologies offer the potential to support decentralisation and the extension of the HHT service portfolio The potential benefits of current investment in IM&T needs to be maximised Page 5

B. SWOT ANALYSIS B.1 STRENGTHS Themes and supporting evidence: THEME EVIDENCE Key internal strengths are: New, skilled and experienced Executive Management Team Self diagnosis HHT is a small, single site provider 2007/08 income totalled Xm; HHT operates from the County Hospital site in Hereford City. Although ambulatory care is provided in community settings across Herefordshire and Powys, these community facilities are neither owned nor operated by HHT Increasing expertise in service redesign/productivity improvement/lean LEAN has been applied to the following services ALAN DAWSON TO NAME. The lead Clinical Systems Engineer for the Trust has a PhD in this subject Clinician enthusiasm for Service Line Reporting/decentralisation of decision making Outputs from clinical strategy workshops An increasing recognition across the organisation that good housekeeping needs to be replaced by organisational transformation Key external strengths are: Consistent delivery of access targets/compliance with core Standards for Better Health Outputs from Executive Management Team, Strategic Forum and Great Escape meetings/events PETER GORIN TO INSERT Page 1

Relative efficiency HOWARD ODDY TO INSERT (06/07 RCI of 95) Provision of a broad range of secondary care/dgh services Self diagnosis Modern hospital environment The new County Hospital was opened in YEAR??? High levels of ownership of and identification with the County Hospital amongst local residents Feedback from GPs, Members, OSC, MPs and other stakeholders Supportive local media Cuttings archives/support for FT application process Implications: HHT has the necessary ingredients for success Internally, it has an effective management team, it is free of the complexities resulting from large size or split site working, it has buy in from the clinical teams, it recognises the need to change clinically and has the technical skills set to do this. Externally, the Trust is able to evidence compliance with core Healthcare Commission standards, relative efficiency, a range of services consistent with its role as a local District General Hospital, modern facilities, a supportive/loyal customer base and a positive media image B.2 WEAKNESSES Themes and supporting evidence THEME EVIDENCE Key internal weaknesses are: Under-appreciation of the threat to the organisation represented by PEST analysis Outputs from clinical strategy workshops Page 2

Structure that is not fit for purpose Outputs from clinical strategy workshops Systems and processes that are not fit for purpose planning, financial and performance management Self diagnosis Lack of change management capacity/capability Self diagnosis Poor quality operational, clinical and planning information; inadequate IM&T systems Self diagnosis PFI financed facilities:high fixed costs; inflexibility in use of facilities Treasury (October 2007) put HHT PFI charge 2008/9 12.6m or 13.4% of 2006/7 turnover; this percentage cited a third highest of all PFI schemes in NHS England Historic dependency on non-recurrent measures to deliver financial targets HOWARD ODDY TO INSERT Poor track record in the delivery of CIPs/ failure to deliver target CIP and surplus in 2007/08 HOWARD ODDY TO INSERT Limited knowledge of profitability of individual service lines JOHN HOWDEN TO INSERT Mixed track record in the recruitment and retention of high quality staff Self diagnosis Lack of a market driven business culture at the middle management and across the clinical teams Feedback from Birmingham and Black Country SHA on HHT wave 3a FT application Page 3

Historical lack of ambition and willingness to selfpromote Key external weaknesses are: Continued used of three WWII temporary wards High occupancy levels resulting from high levels of emergency admissions and hence a negative impact on elective capacity High levels of cancelled operations 67 general and acute beds (30% of general and acute bed stock) accommodated in hutted wards Average bed occupancy level is c.98%. INSERT LATEST PERFORMANCE DATA ON LEVELS OF EMERGENCY ADMISSIONS AND ACTUAL V CONTRACT ON ELECTIVE ACTIVITY INSERT LATEST PERFORMANCE DATA ALAN DAWSON TO INSERT Continuing problems in the delivery of 18 week RTT times Insert latest performance data ALAN DAWSON TO INSERT High levels of HCAIs Sub-optimal stroke care Outputs from clinical strategy workshops Over-centralisation of ambulatory care services on the County Hospital site Inconsistency in service quality/lack of clear quality USP (eg faster access times)/provision of a lower quality service than Gloucestershire Hospitals NHS Foundation Trust (HHT s main competitor) Comparative data from Healthcare Commission website, Dr Foster Good Hospital Guide and NHS Choices website Feedback from GPs Page 4

Poor standard of customer care to GPs Implications: HHT s potential success could be compromised by a mixture of internal and external weaknesses. The organisation needs to develop and execute an Organisational Development programme which delivers an organisation that is fit for purpose and addresses systems, structure, strategy, skills, staff. shared values and style (ie all elements of the McKinsey 7S model) The Trust also needs to ensure that it engages with its customers, develops and implements a more attractive model of care and delivers tangible improvements in quality thus enabling it to differentiate itself from its competitors. Specifically, HHT needs to reprovide the hutted wards, protect the flow of elective patients, adopt a zero-tolerance approach to infection prevention and control and fill any gaps in service provision B.3 OPPORTUNITIES Themes and supporting evidence: THEME Expansion into the eastern part of central Wales through codification of relationship with Powys LHB, development of ambulatory care services at Llandrindod Wells community hospital and post downgrading of Nevill Hall Hospital EVIDENCE Market analysis Capture of an increased percentage of market on the borders between Herefordshire, Gloucestershire, Worcestershire and Shropshire Market analysis Page 5

Diversification eg acquisition of PCT provider arm services, social care, primary care support (diagnostics, accommodation etc), niche services (terminal care, lifestyle services, chronic disease management etc) Market analysis Implications: HHT has opportunities to expand into eastern Wales and increase its share of the local NHS England along the borders with Gloucestershire, Worcestershire and Shropshire. It also has a number of opportunities to diversify. B.4 THREATS Themes and supporting evidence: THEME Relatively small size of HHT catchment population and vulnerability of some services EVIDENCE Herefordshire s resident population totals X; the catchment population of Powys covered by HHT totals Y The report of the Academy of Royal Colleges Acute health care services report of a working party (September 2007) and WMSHA s strategic framework Investing for Health (September 2007) identified paediatrics, obstetrics, A&E and emergency surgery as potentially vulnerable Failure of commissioners to articulate clear strategy for local health economy/economies Lack of up-to-date commissioning strategies which inform LDP negotiations Cost pressures resulting from lack of critical mass and operation in a tariff based market The replacement of a cost = price system with a fixed tariff based system has resulted in HHT being exposed to a range of cost pressures in services which the costs of delivering a safe/high quality service exceed tariff based income Higher co-morbidity of an Page 6

older catchment population resulting in higher costs potentially exceeding tariff income Ineffective joint working across the Herefordshire health and social care system resulting in HHT effectively crosssubsidising provider agencies Age profile of HHT s catchment population and patient workload Distance from optimum ALOS and day surgery rates Historical financial performance of HHT Insert latest data on delayed discharges and n:f/up ratios (versus PCT target of 1:1)and inappropriate referrals Lack of political support within NHS Wales for use of English provider Patient Choice, commissioner preferences and competition from local private sector and Gloucestershire NHS competitors resulting in reduced market share along the borderlands and within HHT s core catchment area +MARTIN WOODFORD TO INSERT Market analysis Establishment of an aggressive community service provider able to cherrypick lo tech outreach and/or diagnostic work Market analysis Development by Practice Based Commissioning Groups of primary care based alternatives to HHT services Market analysis Implications: HHT s potential expansion could be compromised by the loss of vulnerable services and a combination of issues relating to critical mass, the increased costs associated Page 7

with delivering services to a small catchment population in a rural setting and the overall effectiveness of the local health and social care system The Trust s main commissioners have yet to confirm their strategic intentions. The new administration in Wales has signalled that it wishes to minimise/terminate the use of English providers. The organisation is vulnerable to competition from Gloucestershire Hospitals NHS Foundation Trust, new market entrants able to cherrypick lo tech cases and the transfer of care from a hospital into a primary care setting. Page 8