March 2014
1. Executive Summary The Trust is embarking on a three year journey to deliver sustainable, high-quality care through grip, people and productivity, and system redesign. 2013/14 has been a year of embedding our clinical leadership model to ensure all aspects of performance are delivered experience, quality, people and financial all underpinned by our robust Accountability Framework. Central to this has also been the defining and embedding of our values. The focus for 2014/15 is to support our people to drive up our levels of productivity. To do this we must enhance the robustness of our processes and capacity to ensure we deliver our commitment to every patient every day. This work has started with extensive analysis undertaken to identify productivity opportunities, which is supporting our CIP in 2014/15. We have improved our approach to commissioning negotiations, with greater clinical leadership, to ensure we have contracted activity which supports sustained delivery of access standards. We have also been active partners in QIPP and BCF discussions and will work with our Commissioners to implements robust schemes as we recognise the financial pressures facing the whole health economy. In 2014/15 we are also preparing for the challenges in 2015/16. We are implementing an approach to talent management so that the Trust has the capacity and capability to deliver its plans. We continue to invest in clinical information systems and develop new ways of working, brought about by supporting innovation. This will allow evidence based decision making at all levels to unlock opportunities to improve the effectiveness of services. 2015/16 is the year when we begin to bring to life our shared vision of an Integrated Care Model, with the opportunity that the Community Services tender brings, underpinned by productive people and an estate that is increasingly efficient and user friendly. This will build on the work we have undertaken in embedding clinical leadership and our Accountability Framework 2
2. Introduction and background 2.1. Ipswich Hospital Ipswich Hospital is here for around 390,000 people in Ipswich and East Suffolk, and every day over 3,000 people rely on us to improve their lives. Our services include A&E, emergency and critical care; planned medical and surgical care; consultant and midwife-led maternity, and neo-natal and paediatric care; and diagnostic and therapy services. We also provide a range of specialised services including spinal surgery, radiotherapy and gynaecological cancer surgery to a wider catchment of more than 500,000. 2.2. Planning process This plan provides an overview of the priorities, challenges and standards the Trust is setting for 2014/15 and into 2015/16. The detail is inevitably focussed on next year, but many of the themes will continue into 2015/16, and in 2014/15 we will be preparing for the major challenges that 2015/16 brings - the community services tender and the major financial shift in resources into the Better Care Fund (BCF). The planning process we have undertaken is summarised below: Month October November December January February March Action Board received first draft of corporate objectives and planning guidance. Divisions presented summary planning issues and priorities to Combined Board. Board sub-committees reviewed first draft corporate objectives. Divisions submitted first draft plan. Board received an update on development of corporate objectives. Divisions received feedback from Executive team on first draft plan. Board received a planning update and summary of issues from initial plan submission made to TDA Divisions submit second draft plans and present to Trust Board for scrutiny. Board received an update on Trust Planning Assurance Template, Confirm and Challenge meeting with TDA, and issues from 1 st full draft plan submission to TDA. Divisions approve Divisional plans and budgets. Board approves Annual Budget and Business Plan. 3
3. Priority issues facing the Trust 3.1. The Trust faces the following issues over the period 2014-16: Clinical labour market conditions present a key risk, presenting itself in hard-to-recruit posts and shortfalls in junior doctor rotas. Each Division has been identifying workforce risks through their business planning. Organisational capability and capacity is being managed through the further development of a Talent Management programme throughout 2014/15. The Trust is a consortium member of the Transforming Pathology Partnership (TPP) which we expect to go live from 1 st May 2014. Although TPP will not be introducing radical changes immediately, the Partnership still presents a very different way of working for the Trust. With improved demand planning and more robust management processes the Trust does not currently predict that there will be further breaches of access standards in 2014/15. Divisions have developed plans to ensure all specialties have a buffer between scheduled and maximum waiting times and thus ensure that elective waiting time access standards are delivered. The financial challenge facing the whole health economy and wider public sector is a key challenge for all parties. QIPP and BCF fund proposals have and are being developed through extensive joint working with Commissioners and stakeholders, as this is the route to deliver a sustainable health system. However we must ensure that plans are deliverable, allow the hospital to deuce cost alongside activity and income, and fairly balance risk between partners. The full extent of the QIPP schemes impact remains unknown and so the Trust will need to ensure that it is able to respond flexibly to the potential for activity reductions. The Trust is undertaking an assessment of safe staffing requirements which is being factored into financial and workforce plans, alongside our QIPP assessment. We will also be providing more flexibility in provision of our services by extending the hours of operating during the day and at weekends in order to reduce mortality variation, derive greater efficiency, and improve patient experience. Pilots were established over the winter period with a formal joint review with the CCG taking place in early 2014/15. The development is being supported by CQUIN with an initial focus on diagnostics and senior clinical intervention, and is being further supported through our work on the clinical strategy. 4
The CIP target of 14.3m for 2014/15 is circa 6% of costs/revenue, and represents a stretching target. Whilst the plan is not without risk, the development of detailed plans is progressing well, and our approach is to reinforce strict governance protocols before CIPs are signed off and values removed from budgets. The Finance and Performance Committee are overseeing the process and progress of CIP planning and a contingency has been built into the financial plan. 3.2. TDA support: Cash presents a significant financial challenge, and the Trust is seeking support of 8m in early 2014 (in the form of a Temporary Borrowing Limit converted to Public Dividend Capital). This level of support would provide the Trust with adequate cash balances despite forecast deficit, CIP delivery skewed towards latter part of the year, working capital and capital investment demands. The trust would welcome support from the TDA in identifying best practice in developing integrated care as a future model. The Trust sees the development of an Integrated Care Organisation (ICO) as a route to organisational sustainability. 5
4. Trust objectives 4.1. Objectives for 2014/15: To deliver our commitments to every patient, every day Embed Trust values. A workforce led project has been established, supported by the Workforce and Education committee, with CQUIN milestones and funding supporting response rate improvements. Finalise behavioural standards A&E response rate >15% Inpatient response rate >25% Develop patient care and experience improvement plan Q1 Q2 Q3 Q4 Map values into people processes appraisal and personal development Implement FFT in DC and OP departments Develop plan following national patient survey results Outpatient experience transformation work complete Map values into people processes recruitment and selection Complaints task force recommendations implemented Map values into people processes performance management A&E response rate >20% Inpatient response rate >30% (>40% March) Reduce A&E, inpatient & maternity negative responses Set and deliver high standards for patient experience, access and clinical quality, with a rigorous focus on reducing variation in performance. Divisional business plans are addressing how new standards will be met through quality governance and capacity planning. Monitoring will occur through Performance Meetings. Safety thermometer >95% SIRIs<1.23/1,000 bed days Review mortality management arrangements Establish Safer Care programme Safety thermometer >95% SIRIs<1.23/1,000 bed days Implement new Trustwide Mortality Review group Safety thermometer >95% SIRIs<1.23/1,000 bed days Max 6 week OP wait Max 2 week diagnostic wait Safety thermometer >95% SIRIs<1.23/1,000 bed days Average cancer treatment time = half national standard Set and achieve high standards for staff satisfaction. Launch Building Pride initiative Rollout of initiative Evaluation of Building Pride initiative Set and achieve high standards for workforce development and accountability. Develop Learner Voice programme Implement findings of post implementation review of Clinically Led Organisation New Associate Medical Director for Medical Education starts Ensure all staff have a development plan and clear, agreed objectives. Improved HEEE PQAF and GMC survey feedback 6
Clinical improvement priorities Risks from BAF and opportunities have been addressed through Divisional plans. Development of business cases will be tracked through Performance Meetings. Specialist services derogation plans agreed Evaluation of extended working winter pilots VitalPak investment decision Elective transformation scope service and finances Pass JAG accreditation TPP contract review Elective transformation identify KPIs and start service specification Elective transformation stakeholder consultation and redesign Compliant APU 70% key trained staff in end of life care Elective transformation implement changes Build for the future Q1 Q2 Q3 Q4 Build a reputation for delivery with our stakeholders and regulators. Improved planning and more robust risk and performance management at divisional level will ensure plans are delivered. Monitoring will occur through Performance Meetings Achieve a TDA governance risk rating of green to a maximum of amber/green. Deliver 90% CQUIN Achieve a Monitor Continuity of Services risk rating of 3 TDA GRR< amber/green. Deliver 90% CQUIN Monitor CoS rating of 3 TDA GRR< amber/green. Deliver 90% CQUIN Monitor CoS rating of 3 CQC visit TDA GRR< amber/green. Deliver 90% CQUIN Monitor CoS rating of 3 Set and deliver high standards for efficiency. Transformation and productivity groups have been established, with a strengthened transformation team, to support Divisional plans to improve efficiency. Review of reporting and standardisation of processes will underpin specialty specific plans. Monitoring will be through Performance Meetings. Deliver CIPs No budget variance Deliver targets for theatre and clinic utilisation, and length of stay Deliver CIPs No budget variance Deliver targets for theatre and clinic utilisation, and length of stay Deliver CIPs No budget variance Deliver targets for theatre and clinic utilisation, and length of stay Deliver CIPs No budget variance Deliver targets for theatre and clinic utilisation, and length of stay Build capability and capacity to respond to new business opportunities. Stroke ESD ITT Dermatology ITT NHS 111 and out of hours tenders initiated Cardiology ITT MSK physio ITT Community services tender initiated Develop the hospital s infrastructure. New finance systems live Develop HR transformation plan Deliver innovative practices to improve patient care. New Research and Innovation strategy launched Embed links with Academic Health Science Centres Review impact of simulation suite 7
Shape our future Q1 Q2 Q3 Q4 Be an influential leader in the health economy. We will be an active participant in system wide groups and ensure full representation in clinical networks Updated engagement strategy Identify clinical and management leads for all system wide working groups 95% Trust attendance Develop the case for ICO 15/16 BCF decisions taken 95% Trust attendance 95% Trust attendance 95% Trust attendance Progress standalone application for Foundation Trust status. The Foundation Trust Steering Board will oversee the progress of our application, working with the TDA to develop a timeline. Five year IBP and LTFM delivered by 20 June BGAF and QGAF assessments undertaken Launch consultation Due diligence initiated Successful CQC visit Enter Monitor process Construct clinical and support service strategies to improve clinical and financial viability for each service. Strategy communicated Support strategies refreshed Review business planning process Submit commissioning intentions developed from clinical strategies Initiate business planning for 2015/16 Initiate the next stage of leadership development. Initiate Master class programme Next stage of talent mapping Identify and develop talent pool Implement talent interventions 4.2. Objectives for 2015/16: Many of the objectives for 2015/16 will be focussed on sustaining and embedding the improvements made in 2014/15 people and productivity. New objectives will focus on sustainability and system redesign and will centre on the community services tender and estate rationalisation. This will be underpinned by the work we are undertaking on clinical service strategies and system engagement in QIPP, BCF and system-wide redesign, and building commercial capability and capacity. 8
5. Risks and opportunities 5.1. Risks to delivery of service objectives and mitigation plans The financial challenge facing the NHS can be translated as an ambition to reduce emergency admissions by 15% and improve elective productivity by 20%. Activity reductions of this magnitude pose a significant risk to the clinical and financial sustainability of the Trust and the wider health economy, so it is important that we remain a fully active partner in helping to shape robust BCF and QIPP schemes with all partners in the health economy. It is essential these schemes deliver major improvements in total health spend effectiveness, and do not simply shift the balance of financial burden between commissioners and providers. Continued engagement with senior clinical and management representation is essential. Clinical labour market conditions with hard-to-recruit posts and shortfalls in junior doctor rotas also present a risk to delivering activity and capacity. In mitigation each Division has been identifying workforce risks through their business planning, and the Trust will be supporting a co-ordinated approach to address each risk e.g. productivity, role redesign, internal training and development (grow our own) linked to UCS and other Universities, or wider national and international recruitment. The Trust is also working with the Deanery to ensure we significantly improve our educational experience and outcomes, and elevating the place to learn aspect of our organisational role alongside place to work and be cared for. A new Board sub-committee and workforce metrics are in development to manage risk in this area. The Trust is establishing a Safer Care programme to address workforce development. Organisational capability and capacity is being managed through the further development of a Talent Management programme throughout 2014/15. The Transforming Pathology Partnership (TPP) pathology transformation will go live on 1 st May 2014. The Trust is currently focussing on clinical governance arrangements and the interface with consultants to improve redesign outcomes. Investment is also being made in contract management arrangements to support this new way of managing pathology services. 9
Finally a number of services are being tendered in the period 2014-2016. Some are for services we currently provide, and others reflect new opportunities to expand into community services. Investment is also being made to support the organisational capability and capacity to submit successful tenders. 5.2. Financial risks and opportunities Financial risks are being managed in the following areas: Activity levels. We will work in partnership with Commissioners to support the initiative to deliver more activity closer to the patient s home where this is clinically and financially feasible. Delivery of cost improvement plans. The Trust has identified a number of areas where it can be more productive, maintain or improve quality and reduce costs. Whilst the degree of risk to delivery in each scheme is variable the schemes have been developed by the divisions and a robust programme to oversee and support delivery is now in place. While the Trust faces a number of risks to service delivery, there are also opportunities: The Ipswich Heart Centre presents a real opportunity to attract private, extended catchment and potentially emergency activity to the Trust. A number of tenders represent opportunities, including Cardiology, Dermatology, and Stroke Early Supported Discharge (joint tender response with West Suffolk Hospital). Market expansion opportunities have been identified for spinal, ophthalmic, maternity and hepatology services. Market opportunities are also emerging for TPP, in which the Trust will share 20% of any benefit. 10
6. Service plans 6.1. Activity and capacity The Trust has now reached agreement with the CCG n the contract for 2014/15 and signing of the contract is expected to conclude on 28 th March. The Trust has identified a number of factors that will increase the demand for activity in 2014/15 and the commissioners have put forward a number of schemes as part of their QIPP programme which intend to reduce activity at the Trust. The basis of the agreement is for no growth in activity and the Trust has negotiated a 2.3% ceiling over contract levels before any formal contractual review mechanisms are initiated. The figure is the Trust s assessment of growth before QIPP initiatives. During the detailed engagement with divisions there were a number of specialties where the variation in demand and capacity were expected to provide further divisional challenge:: Cardiology estimated 10% growth, new Heart Centre impact and upcoming tenders for diagnostic and community cardiology work. Dermatology current tender for integrated Dermatology service and new model of delivery, with shift of care into community settings. Nephrology and neurology demand growth in excess of 10%. General surgery, urology, trauma and orthopaedics, and oral surgery which have experienced capacity and access issues during the year. Market expansion and tendering opportunities for spinal, ophthalmology, maternity and bowel cancer screening services. Oncology day unit capacity. Clinicians will also be fully involved in assessing ongoing development of QIPP initiatives and understanding the impact on their service. Divisions will then need to support the development of plans to implement the changes as they are jointly worked up with the CCG. The Trust will ensure trigger mechanisms are in place providing early warning of variation in demand, providing sufficient time to implement changes to capacity. 11
6.2. CQUIN projects The CQUIN plans have been finalised with the exception of 7 day working which will be completed once the impact of the winter schemes have been fully evaluated. Goal Name Description of Goal Goal Weighting (% of CQUIN scheme available) Expected Financial Value of Goal Friends and Family Test Improving Patient Experience 5.00% 208,750 NHS Safety Thermometer Reducing falls and pressure ulcers and 7.75% 323,563 introducing medications safety Dementia Improving Care for patients with Dementia 7.25% 302,688 Psychiatric Liaison Extend and embed Psychiatric Liaison service to 7.50% 313,125 improve access Elective Transformation Support to development of revised elective 29.00% 1,210,750 pathways Deteriorating Patient Early identification and better management of 6.25% 260,938 deteriorating patients Shared Care Drugs Development of processes to support shared care 2.50% 104,375 drugs 7 day working Extension of the provision of some services to 25.00% 1,043,750 support the delivery of Keogh s 10 Clinical Standards End of life Improving choice and dignity 2.75% 114,813 Surgical Liaison Geriatrician Support management of falls reduction, delirium 4.00% 167,000 and frailty identification Gallstones Redesigned pathway 3.00% 125,250 Total 100.00% 4,175,000 12
7. Quality Our Quality Strategy sets out three objectives which relate to safety, effectiveness and compassionate care: 7.1. Building a Patient Safety Culture Vital in any healthcare environment is both a focus on patient safety and a culture where we willingly share experiences, learn from things going wrong and proactively use risk assessment and monitor improvement. Our values underpin all that we do and these very intentionally include the need to continually improve, speak up and keep our patients safe. The Trust will operate within a well-developed governance and incident reporting procedure and promote an open, learning culture. The Trust will aim to eliminate all avoidable harm to patients by the prevention of errors and adverse effects to patients associated with health care. We will create a patient safety culture by: Patient safety improvements To be a high reporter of clinical incidents Implementation of effective falls reduction programme and elimination of avoidable pressure ulcers Reduction and prevention of medication errors Minimise the rate of Healthcare Associated Infections 7.2. Building a Clinical Effectiveness Culture The Trust will build on our well established culture of monitoring clinical outcomes and learning from best practice examples to improve the quality of health outcomes for our patients, as set out in the NHS Outcomes Framework and NICE Quality Standards. We will improve clinical effectiveness by: Identifying areas for improvement in line with emerging evidence base Developing guidelines, learning from audits and enquiries Local 98% Venous Thromboembolism (VTE) target 13
Ensure audits are in line with organisational risks and priorities Further develop care for specified patient groups Redesign of care pathways Monitor and act on benchmarked mortality and morbidity data 7.3. Building a Patient Experience Culture Our work on the Future of Care to develop our values has great patient experience at its core. In addition to building our clinical effectiveness as above we will work with our patients to improve this experience. Our revised operating structures build in the importance of the patient voice at more levels than ever before and we will look to build on this valuable experience. Our exceptional relationship with our community is reflected in the quality of our active hospital user groups (such as IHUG) and the number of volunteers and fundraisers we have. These individuals and groups keep us closer to our patients and we will continue to use them in addition to patient feedback, thanks, compliments and complaints to shape our plans Whilst we have an obligation to include patients, stakeholders and the public at the earliest opportunity in the review, reorganisation and planning of services we will go further than our legal obligations to welcome feedback from all of those who experience the care we provide. We will improve patient experience by: Identifying areas for improvement in line with emerging evidence base Develop our range of patient experience feedback routes Complaints, concerns and compliments will be addressed quickly and appropriately Optimise patient experience pathways for key groups such as Older People Pathway Group, Children and Young People Pathway Group, End of Life Group, and various user groups covering patients, carers and community representatives. Further develop and support the services provided by volunteers Monitor the leadership of patient experience and quality of care Use Future of Care values to inform recruitment and standard of behaviour Develop relationships between patients and professionals and increase community participation Increased staff awareness at all levels 14
8. Financial plans 8.1. Income and Expenditure account The table below presents the 2014/15 Trust budget which produces a 4.9m deficit. This is an improvement on the underlying 2013/14 deficit, and in line with the agreed financial strategy of moving towards break-even in 2015/16. Divisional Budget Summary 2014/15 Division 1 Division 2 Division 3 Division 4 Division 4 2014/15 Budget m m m Corp m Fin/Res m m Paper m Income 61.5 83.4 53.1 13.5 26.3 237.8 237.6 Pay (49.3) (50.0) (32.7) (16.5) (2.6) (151.1) (151.3) Non-pay (11.3) (15.5) (8.5) (31.0) (24.6) (90.9) (90.4) Surplus/(deficit) before financing 0.9 18.0 11.9 (34.0) (0.9) (4.1) (4.1) Financing (0.0) 0.0 (0.1) (1.6) (13.4) (15.1) (15.1) Net surplus/(deficit) before CIP 0.9 18.0 11.8 (35.6) (14.3) (19.2) (19.2) CIP 3.8 3.9 2.5 4.1 14.3 14.3 Net surplus/(deficit) after CIP 4.7 21.9 14.3 (31.5) (14.3) (4.9) (4.9) Points to note within the budget are: The budget delivers in excess of the tariff efficiency target of 4%; NHS clinical income is modelled on a flat activity profile, consistent with Commissioner contracts; Non clinical income is maintained at 2013/14 levels; Inflation reserves for pay and non-pay are held within Division 4; The Trust has established a general contingency reserve. 15
8.2. Cost Improvement Programme The chart below shows the allocation of 14.3m CIP target between Divisions and the value of CIPs fully developed against this target. This only includes CIPs which have been through the full governance process. Divisions continue to forecast development of plans to 90% of the CIP target to be in place by the end of March. m 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 - Division 1 m Division 2 m Division 3 m Division 4 m CIPs unidentified - 3.9 1.2 3.1 CIPs identified and developed 3.8-1.3 1.0 CIPs target 3.8 3.9 2.5 4.1 8.3. Capital programme The Capital Investment Group has reviewed and agreed the outline capital plan for 2014/15 within a planning total of 9.5m. Budget Summary 2014/15 - Capital Investment m Major schemes 4.2 Estates projects 1.6 IM&T projects 1.2 Equipment 1.3 Contingency and reserves 1.2 Total 9.5 Major schemes are based upon known BAF risks and known risks to clinical service delivery. A detailed process has been undertaken to assess the equipment priorities based upon an assessment of safety, patient experience and finance (equally split). The estates priorities are subject to a 6 facet review and will be established in Q1. IM&T plans are being reviewed alongside Divisional business plans to ensure they are consistent. 16
9. Charitable funds 9.1. Vision The Ipswich Hospital NHS Trust s Charitable Funds vision is to maximise donations to the Charitable Fund in order to help deliver the Trust Strategy and drive continuous improvement in patient experience. In delivering this vision we will: Invest wisely and in a timely manner in innovation, education, facilities, and staff welfare. Administer the Fund in a prudent and professional manner, respecting the wishes of donors at all times. Support the work of the Trust in providing the best possible healthcare to its patients; Support the work of NHS staff and allows the Trust to continue to raise standards for patients, their carers, staff and students. 9.2. Strategic Goals The Trustee s overarching strategic goals for the Charitable Fund are: Good governance, Higher profile, and Sustainable growth in funds raised and spent. 9.3. Delivering these strategic goals Under pinning these strategic goals will be work streams that will be overseen by the Charitable Funds and Sponsorship Committee. The implementation plan is split into three phases: Governance Profile Sustainability 13/14 14/15 Q4 Q1 Q2 Q3 Q4 17
10. Aligning strategy, objectives, performance and values Vision currently out to consultation The team you trust Build for the future Our vision is delivered through our objectives Deliver to every patient every day Clinical Quality Shape our future Value for Money Our objectives are measured through our Accountability Framework Patient Experience Staff Satisfaction Reputation Friendly Kind Involved Safe Efficient Skilled And everything is underpinned by our values 18
11. Accountability Framework The Trust has an established Accountability Framework used for monthly Performance Meetings with each Division. The metrics have been reviewed against new priorities and CQC domains, and the following changes are proposed. A further review will be undertaken following the release of the TDA s Accountability Framework in April 2014: 11.1. Patient Experience The elements of the patient questionnaire that link to our values will be included. The discharge questions will be included to ensure that we provide the best experience to patients and carers whilst patients are in hospital and through the discharge process Access targets will be adjusted to meet our ambitions of no patient waiting longer than 6 week for an outpatient appointment, 2 weeks for a diagnostic test, and providing an average treatment time for cancers of half the national standard. 18 week assurance milestones will also be embedded into the Accountability Framework A new measure will be included which identifies all patients who have been cancelled more than once. 11.2. Clinical Quality We will continue to monitor never events (zero tolerance) and SIRIs (threshold rate of 1.23 per 1,000 bed days as per current TDA Accountability Framework), and monitor the trend on SIs. However we are keen to avoid a perverse incentive of discouraging reporting of incidents. Monitoring will extend to safety thermometer, MSSA and potentially e-coli. Clinical audit participation will now be monitored, as will timely adoption of NICE TAs. This will also facilitate approval with funding decisions from Commissioners. PbR assurance questions will also be included to ensure the accuracy of coding and clinical data quality. 11.3. Staff satisfaction Staffing ratios will be monitored, linked to our safe staffing reviews GMC and Deanery survey results will also be monitored at a Divisional level. A review of domains against Committee structures will be undertaken to ensure all areas are covered in detail at sub-board level. 19