Meeting Date: 18 July 2013 - Shropshire Community Health ... · 2.3 Transfer of Adult Learning...

1 Accountable Director: Julie Thornby, Director of Governance & Strategy and Tessa Norris, Director of Operations Board Meeting Date: 18 July 2013

SUMMARY REPORT

Meeting Date: 18 July 2013

Agenda Item: 9.1

Enclosure Number:

7

Meeting: Trust Board

Title: Trust Service Development and Tender Update

Author: Vic Middlemiss, Deputy Director of Governance and Strategy

Accountable Director: Julie Thornby, Director of Governance and Strategy Tessa Norris, Director of Operations

Other meetings presented to or previously agreed at:

Committee Date Reviewed Key Points/Recommendation from that Committee

Resource & Performance

1 July 2013

Content of the report noted

Purpose of the report

To brief the Board on latest tender submissions, service developments or transfers.

Decision/ Approval

Assurance

Discussion

Information

Strategic Priorities this report relates to:

To exceed

expectations in the

quality of care

delivered

To transform our

services to offer more

care closer to home

more productively.

To deliver well co-

ordinated effective care

by working in

partnership with

others.

To provide the best

services for patients by

becoming a more

flexible and

sustainable

organisation

√

Summary of key points in report

The Trust still intends to enter a revised bid for Integrated Drug Treatment Services and we await the tender advertisement.

A number of Health Improvement (HIMP) Services in Telford and Wrekin have now been decommissioned, as of 28 June 2013.

Transfer of Adult Learning Disability Nursing Services from South Staffordshire and Shropshire Mental Health NHS FT to the Trust has been delayed by commissioners in order to finalise agreement on the contract price.

No further news on decisions by commissioners on Trust prioritisation bids

National Trust Development Authority has signed off Trust’s final Annual Plan 2013/14


Key Recommendations

The Board is asked to receive and note this report

Is this report relevant to compliance with any key standards? YES OR NO

State specific standard or BAF risk

CQC No N/A

NHSLA No N/A

IG Governance Toolkit No N/A

Board Assurance

Framework Yes

1099 Inability to grow Trust business leading to sustainability risks

Impacts and Implications? YES or NO

If yes, what impact or implication

Patient safety & experience N

Financial (revenue & capital) Y Loss of contact income through some of changes described

OD/Workforce Y

25 staff redundancies as a result of decommissioned HIMP services

Legal N


Title Trust Service Development and Tender Update

Executive Summary

This paper updates the Board on the current position with regard to current tendering activity, service developments, decommissioning issues and transfers.

Current Position

1. Tenders 1.1 Stop Smoking Services (Telford and Wrekin)

Work has been ongoing for the tender for Stop Smoking Services put out by Telford & Wrekin Council. The bid was submitted on 6 June 2013 for the three separate lots as follows:

Lot 1 Core services – Estimated Annual Value £331,576

Lot 2 Out of Hours – Estimated Annual Value £110,509

Lot 3 Pregnancy – Estimated Annual Value £101,005. A verbal update if available will be given at the meeting.

1.2 Integrated Drug Treatment Services As previously reported, the Trust has indicated an intention to enter a revised bid for the provision of Integrated Drug Treatment Services (IDTS). We are still awaiting further instructions and information from Healthcare Commissioning Services, who are leading this tender process. The Trust’s intention is to assess the quantity of work when the tender goes live to inform internal and external resource requirements, and form a project team to work up a bid.

1.3 Non-emergency Patient Transport (NEPT) Shropshire County CCG is leading on a tender exercise for non-emergency patient transport. This is

a health economy-wide tender to which we are a recipient of the service, along with Shrewsbury and Telford Hospitals NHS Trust, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS FT and South Staffordshire and Shropshire Mental Health NHS FT. Our role is therefore as an ‘associate commissioner’ to the tender process and to the subsequent contract. The tender represents an opportunity to update the specification to reflect the Trust’s current and future requirements, improve the quality of service and reduce NEPT expenditure across the health economy. The latest position is that the service specification is being finalised and the tender will be advertised in August. Following tender award, the new contract is not due to come into effect until July 2014.

2. Decommissioning/ service transfers

2.1 Health Improvement Services

Following the decision of Telford & Wrekin Council to decommission a variety of Health Improvement services previously provided by the Trust, a number of services ceased to be provided on 28th June 2013. These included: - Community Food Programme - Alcohol and Workplace for Adults - Emotional Health and Wellbeing for Adults (excluding the Green Gym Project) - Alcohol and Emotional Health and Wellbeing for Children and Young People - All Physical Activity Programmes


- Health Information and Outreach - Community Engagement - Support Services (Administration Team) Of the 28 staff affected by the changes, 25 were made redundant, while two people were re-deployed within the Trust and one staff member re-deployed elsewhere in the NHS.

2.2 Transfer of Orthopaedic APCS Services to RJAH

As stated at previous meetings, the Community Trust had been issued with formal notification of Shropshire County CCG’s intent to transfer the APCS Orthopaedics service to the Robert Jones and Agnes Hunt Hospital Trust (RJAH). The intended transfer date is 1 August 2013.

2.3 Transfer of Adult Learning Disability Nursing Services The transfer of the Trust’s Learning Disability Nurses, who are currently managed by the local authority, to South Staffordshire and Shropshire Mental Health NHS FT has been planned for a significant time. This has been delayed by commissioners in order to finalise agreement on the contract price. At the time of writing this report, the Trust is still awaiting a final date for transfer.

3 Service developments Both CCGs had previously indicated that they had deferred final decisions on the bids submitted to them for their prioritization processes until after contract finalization. There has been no further news on this.

4 Trust Annual Plan – see appendix 1 The National Trust Development Authority has signed off the final version of the Trust’s Annual Plan with no further changes required. This version was submitted at the end of April after various discussions on its different iterations by the Board and the Resources and Performance Committee on its behalf. The Plan is attached at Appendix 1.

Board Action Required

The Board is asked to: i) Note this report and ratify the final Annual Plan now approved by the TDA.

www.shropscommunityhealth.nhs.uk

Shropshire Community Health NHS Trust

Annual Plan2013/14

Final submission to TDA

April 2013

Appendix 1

Slide 2


Overview

This presentation is structured as

follows:

1. Trust context

2. Review of 12/13 performance

3. Plans for 13/14

4. Key challenges

5. Improvement Priorities

6. Development Priorities


1. Local Strategic Context

• Specialist community trust with dispersed population covering the largest, inland, rural county in England.

• 18 months in operation - formed from merger of 2 PCT Provider arms in July 2011

• Local health economy features higher than average elderly population which is increasing, plus continuing growth of unscheduled care demand

• Trust offers well established, mobile workforce with large network of community bases

• Local commissioners comprise > 90% of the trust’s current market share

• The trust’s community services are key to achieving the shift from hospital based care envisaged in commissioner priorities- requires system-wide transformation

• Trust see its position as a crucial ‘cog in the mechanism’ for integrated pathways spanning primary/ secondary care, local authorities and other sectors.

• A strategic relationship agreement with Shrewsbury and Telford Hospitals NHS Trust (SaTH) has been developed and projects established in key areas.

• Trust is already involved in delivery against commissioners’ unscheduled care strategy to help shape future service, in particular developing an integrated frail and complex team with SaTH, local authorities, third sector.

• The Trust is seeking to actively contribute to emerging commissioner-led local health economy strategy via Compact formed as at March 2013.

Slide 4


1. Local Strategic Context (2)• The Trust provides a wide range of inpatient, outpatient and home based health

services, covering general care for adults and children and young people such as district nursing, school nursing and health visiting, and four community hospitals alongside more specialist services such as the community respiratory service

• Many of these services already provide 7 day working – other service development proposals lodged with commissioners extend services to offer this (see 13/14 service development slide)

• Healthcare Income is c£74m• Competition for community service provision is increasing from other NHS provider

trusts and from the private sector.• Pursuing standalone FT status – positive achievements include externally assessed

score of 3.5 against Monitor quality framework but main trajectory delayed at SHA request

• The trust’s vision is ‘to be the best local provider of innovative, high quality and accessible services which work closely with the rest of the health and care system to improve the health of the local population.’

The achievement of the vision is underpinned by four strategic objectives:-– To exceed expectations in the quality of care delivered;– To transform our services to offer more care closer to home more productively,

especially services for older people, those with long term conditions, children and specialist services;

– To deliver well-co-ordinated effective care by working in partnership with others;– To provide the best services for patients by becoming a more flexible and

sustainable organisation.


2. Review of 12/13 Performance

Seven key areas:

• Clinical Quality

• Operational Performance Standards

• Workforce and OD

• Service Improvements/ Developments

• Finance

• FT Application

• Board Development

Slide 6


Performance 12/13 – Clinical Quality (1)Quality Review outcome

Clinical Quality Review/ QGF – The Trust’s self assessment against the Monitor quality

framework has been externally assessed in August 2012 by KPMG, who validated a score

of 3.5 (authoriseable)

NHSLA

The Trust achieved NHSLA Level One compliance in July 2012

Never Events

Zero never events have been recorded YTD.

Mortality

A Mortality Group has been set up to review unexplained/ unexpected deaths in

Community Hospitals and Prisons (see further detail on slide 26)

HCAIs

• At March 2013, there have been no cases of MRSA bacteraemia in the Trust

• At March 2013, there have been 6 cases of Clostridium difficile recorded (which is above the local annual target of 4, set prior to introduction of new test). The Trust is participating in a county wide task and finish group to see if there are any further actions that can be taken.


Performance 12/13 – Clinical Quality (2)

Pressure UlcersThe number of pressure ulcers in the community continues to be a concern. A significant amount of work has been put in place across the health economy with collaborative working and additional support by the Pressure Ulcer Prevention Team since Sept 2012 including provision of training for staff and implementation of SSKIN, and a hotline for staff, carers and the public.

VTEThe Trust did not achieve the 90% target per month for this indicator until Oct 2012. Actions were implemented during Q1 and have resulted in improving compliance - 98% in February 2013.

Harm Free CareSafe Care has been led by the Trust and implemented across the health economy and good levels of engagement achieved at project boards and sub-groups. The Harm Free Care rate has increased and was 91.3% in March 2013.

Quality Impact Assessment of CIPSThe Trust initially used the West Midlands approach to QIAs and then Monitor’s best practice guidance and NQB guidance. This was highlighted as part of BGAF review resulting in a formal process being developed and approved by the Board. Monitored via Operational Quality and Safety group and reported through to Committee and Board.

Slide 8


Performance 12/13 – Clinical Quality (3)

CQUIN

The trust is achieving compliance with all CQUIN targets with the exception of VTE

(this was not compliant in Q1 or Q2, but is compliant at Q3)

Patient Experience

Inpatients are asked their opinion on aspects of their care on discharge from

hospital. In Q1 75% of respondents graded their overall care as excellent or very

good. This had increased to 90% by Q2 and 92% in Q3.

Friends and Family test

Implemented in community hospitals during 2012/13 as per CQUIN

requirements, which was achieved. This was extended to our Minor Injury Units from

Oct 2012.


Performance 12/13 – Operational Standards (1)

Operational Performance

Standards (Table 1 of TDA

Planning Guidance 2013/14)

Operational

standard

Dec-Feb

performance

Projected year

end

RTT wait times (18 weeks)

admitted

90% 70.3% <90% for month

92% for the year

RTT wait times (18 weeks)

non-admitted

95% 96.6% <95% for month

95% for the year

Diagnostic test wait times

(6 weeks)

99% 100% 99%

A&E (MIU) waits (4 hours) 95% 100% 99%

Mixed sex accommodation

breaches

Minimise No

breaches

No breaches

RTT wait times (18 weeks) admitted pathways The trust projects the March position to be below target (ie to dip below 90% for the month) due to the position with Oral Surgery (as outlined in Slide 11). Despite this we project the average across the year to be 92%. RTT wait times (18 weeks) for non-admitted pathways The trust projects the March position to be below target (ie to dip below 95% for the month) due to the position with Paediatrics (as outlined in Slide 11). Despite this we project the average across the year to be 95%.


Single operating model –

Governance / Quality

Operational

standard

Dec-Feb

performance

Projected

year end

Access to healthcare for

people with Learning

Disability

4 protocols in

place

4 protocols 4 protocols

Data Completeness:

Community Services

50% 90% 90%

Clostridium Difficile 12 (de minimus) 4 6

MRSA 6 (de minimus) 0 0

VTE Screening 90% 98.0% 98% for month

75% for the year

Avoidable Grade 3 and 4

Pressure Ulcers

0 5 See note below


Avoidable pressure ulcers Projected year end for avoidable grade 3 and 4 pressure ulcers – there have been 4 grade 3 and 4 pressure ulcers in March 2013 but the year end figure for avoidable pressure ulcers is not yet available as root cause analysis reports for the month are currently being reviewed VTE Screening Poor performance occurred in Q1 and Q2 in delivery of this target. However we have achieved 90% in Q3 and project this to be at 98% at year end. However, the Q1 and Q2 performance means that year average will be around 75%. CDiff The operational standard target is 12 although the local agreed target for CDiff is 4 for the year.


Performance 12/13 – Operational Standards (3)Actions to achieve performance standards:

RTT (admitted) – community dental service

12 children and adults, requiring dental conservation and/or extractions under

General Anaesthetics breaching RTT

• Issue relates to historical backlog of patients/problems with theatre capacity at Shrewsbury and Telford Hospitals NHS Trust (SaTH)

• Additional theatre capacity secured at Wolverhampton BMI, via Walsall dental team, to resolve backlog during Q4, and urgent resolution sought with SaTH. (For longer term plan see 13/14)

RTT (non-admitted) – community paediatrics

• Breach for very small numbers of outpatients

• Referral and care pathways redesigned to match capacity to demand, improved monitoring, triage for additional capacity, improved clinic administration – to resolve breaches during Q4

RTT 18 week failure for admitted patients - Community Dental

• As at 27 March 2013, the number breaching has reduced to 12. All are scheduled for treatment in April having had theatre sessions cancelled in March due to escalation pressures at SaTH.

• The issue relates to historical backlog of patients/ problems with theatre capacity at Shrewsbury and Telford Hospitals NHS Trust (SaTH)

• Additional theatre capacity secured at Wolverhampton BMI, via Walsall dental team, to resolve backlog during Q4, and urgent resolution sought with SaTH. (For longer term plan see 13/14).

• SaTH is the only local option for those patients with complex medical histories requiring dental surgery under general anaesthetics, all other patients are being offered alternative provision

RTT failure for non admitted - Community Paediatrics. • Breaches have occurred for a very small numbers of outpatients • Referral and care pathways redesigned to match capacity to demand, improved

monitoring, triage for additional capacity, improved clinic administration – to resolve breaches during Q4

• As of the end of March ‘13, there are no patients breaching the RTT 18 week wait for community paediatrics.



Actions to achieve performance standards (cont):

Avoidable Grade 3 and 4 Pressure Ulcers

•Safecare, harm free project board chaired by the trust for the health economy – task and finish group for Pu’s in place

•Consistent guidelines and policies across local health economy to reflect SSKIN care bundle.

•Director/Deputy of Nursing meeting monthly with team leaders to discuss and determine actions.

•Training always included as part of root cause analysis. Over 100 training sessions and 40 seminars given with good take-up, including the independent sector.

There is consistency across the health economy in relation to guidelines and policies all of which are being revised to reflect the SSKIN care bundle. Community Hospitals are implementing the intentional rounding charts that reflect SSKIN and the team have bid for monies to pay for the printing of patient booklets in the community. Despite all the work and interventions that have taken place there are still avoidable pressure ulcers being seen in SCHT. Regular monthly meetings are being held with either the Director or Deputy Director of Nursing where team leaders are invited to discuss pressure ulcers that have developed in their teams and what actions need to be taken. Training is raised as a specific consideration during the root cause analysis (RCA) process following the development of a pressure ulcer. The number of training sessions across the health economy has increased and attendance has been good including from the independent care sector. The PUP team have delivered over 100 training sessions and the Tissue Viability Specialist Nurse has delivered over 40 mandatory training seminars.


Performance 12/13 – Service developments (1)

Outpatient and

Ambulatory Care

• Increase in outpatient services at Community Hospitals, with further increases in OP and

theatre sessions planned for 2013.

• Implementation of diagnostics in community currently being scoped.

End of Life Care/

Night sitting

• Provision of a night sitting service across Shropshire has been implemented.

• This service is for end of life care, admission avoidance, supported discharge from A&E,

support for frail & vulnerable patients and also short term support to maintain independence

at home.

Intermediate Care

Team Expansion

• Provision of addition therapy input into the Intermediate Care Team in Telford to support

reablement and rehabilitation.

Enhanced Care

Teams

Desired outcomes have been captured through service changes in the IDTs and

development of case managers

AQP Podiatry • Qualified to provide Core Podiatry and Nail Surgery following successful AQP application.

• Provision of high quality clinically appropriate podiatric care efficiently and cost effectively

to increase mobility and independence for adults aged 18 and over

Health Visitor

Expansion

• Incremental increase in HV workforce numbers as agreed with Commissioners

• Health Visitor student placement to support SHA student intake numbers

• Progression to new model of service delivery in line with the healthy child programme as

an early implementer site

The following schemes have been implemented/ progressed during the year:

Slide 14


Performance 12/13 – Service developments (2)

Frail and Complex initiative

The Trust is supporting the CCGs in delivery of a large scale development, linked to

the Unscheduled Care Strategy, associated with frail and complex patients.

This is a whole systems approach to improving care to those patients classified as

“Frail and Complex” using a single assessment tool. Emphasis is on admission

avoidance where appropriate, supported timely discharge and care whenever

possible delivered in the patients home.

As part of this initiative, the Community Trust is involved in four discrete work

areas:

•Diagnostics, Assessment and Access to Rehabilitation and Treatment (DAART)

reconfiguration,

•Therapy and nursing in reach,

•Community Interdisciplinary team work and

•Single point of Referral/ Access


Workforce KPIs Target Outturn

March 2012

Outturn March

2013

Staff turnover <=10% 7.9% 9.1%

Staff sickness rates

(long term rate)

<=3.39%

2.8% 2.54%

Staff sickness (short-

term rate)

1.71% 2.59%

Combined Absence Rate 4.51% 5.13%

Percentage of Vacancies <=3% 2.32% 3%

Percentage of staff

appraisals in the last 12

months

95-100% 58.3% 42%

Overtime as % of total

employee benefit

expense

0.38% 0.38%

Performance 12/13 – HR, Workforce & OD

Slide 16


% Staff Appraisals (by professional group) completed as at 31st March 2013

Performance Review 12/13 – HR, Workforce and OD (4)


Performance Review 12/13 – HR, Workforce & OD (3)

Key Performance Indicators

Employee numbers fell by 4.6% after April 2012, to 1339 WTE by the end of 2012/13, in line with the workforce plan

Turnover has remained low at 9.1%

Current sickness absence averages 5.13% for the 12 months. A series of actions have been taken to reduce staff sickness levels:

• 1:1 HR support to Managers

• Reactive early intervention by Occupational Health via the Initial Sickness Absence Reduction (ISAR) pilot within Community Hospitals

• Provision of Staff Health & Wellbeing Clinics via Occupational Health

• HR/Team Leaders proactive sickness absence management sessions

• Membership of the West Midlands Special Interest Group

• Review of the Sickness Absence policy

• Implementation of Stress Support policy

• Stress Awareness Training sessions

• Monthly data cleanse exercise with Managers

Appraisal rates appear low at 29% - partly due to data collection issues which are being addressed. Mandatory training is a specific area of focus – with ongoing work to target and address shortfalls in uptake by end of March 2013



Recorded appraisal rates are 42% and ongoing conversations with managers have

provided assurance that does reflect the actual position. Data collection has been

manual and is moving to electronic via ESR.

A new appraisal system has been implemented following input from staff to simplify

and move away from E-KSF. Actions include:

• The full implementation of ESR Self Service will support more accurate data

collection.

• New appraisal system implemented, which is not as cumbersome and time-

consuming as E-KSF.

• Training provision for Appraisers and Appraisees is being developed

The target was for all staff to have received an appraisal by the end of March 2013,

this has not been achieved.

Slide 19


Agency Spend

Information on agency spend is collated every month, broken down by department as

well as directly commissioned spend e.g. escalation beds within the Community Hospitals. The

actions being undertaken to reduce agency spend are:

• Proactive sickness management by managers and HR

• Temporary contracts issued

• Work with SATH on an integrated bank as part of Productive Shropshire to commence 1 June 2013. Benefits include improved governance, use of bank

instead of agency and benefits of cross working across organisations.

Mandatory training

Progress against Mandatory Training is currently at 88% YTD which is below the annual target

however, a significant improvement on end of year outturn of 59% at March 2012.

This was a specific area of focus with ongoing work to target and address shortfalls in uptake by the

end of March 2013. Actions to achieve this were:

• Targeting non-attendance by analysis of training data

• Providing further training sessions, focusing particularly on areas where attendance is lowest. This will include bundle sessions

• Ensuring that staff are released to attend

• Use of technology – virtual classroom and video conferencing



Performance 12/13 – Finance (1)

Income, Expenditure and FRR

The Trust is confident of achieving the agreed £1.5m surplus for 2012/13.

At end February, forecast position for the year indicates that total income will

amount to £79.9m, as per plan, and that costs will be similarly in line with plan.

The in year CIP target of £3.5m is forecast to be delivered, albeit with a small

deficit of £0.2m in the recurrent delivery.

The forecast delivers an FRR of 3 in line with plan, and equal to the Monitor

minimum requirement at authorisation.

Slide 21


Performance 12/13 – Finance (2)

Commissioner Relationships and contract delivery 2012/13

Contracts with both main commissioners were signed prior to April 2012 and

there have been no performance notices served on the Trust to date.

Following the establishment of the Trust in 2011/12 all Price and Activity

Matrices (PAMs) with commissioners were rebased with effect from 2012/13.

An interim 2012/13 PAM has been agreed with both main commissioners and

a programme of work to establish an improved basis for the 2013/14 PAM is

currently under discussion. A roll forward has been agreed in principle.

There have been no disputes over the terms of the contracts at any point to

date in 2012/13.


Performance 12/13 – FT Application

• Current TFA date: submission to DoH March 2013

• To date, second draft IBP/ LTFM, Phase 1 readiness review (HDD 1), BGAF and QGF external verification reports all submitted by dates set in TFA.

• QGF externally assessed as authorisable (score 3.5)

• Actions from FT-related assessments in place eg stakeholder engagement plan agreed and being implemented; information and data quality issues being addressed eg flash reports introduced for board

• NHS Midlands and East requested delay to public consultation due summer 2012 (not yet taken place) and postponed Board to Board readiness review meeting. Trust therefore unable to meet TFA dates.

• External BGAF report (September 2012) recommended trust needs additional six months to prepare for FT application. Ongoing discussion with NHS Midlands and East and NDTA; awaiting further discussions with NDTA to clarify future trajectory dates including response to that recommendation

• Emergent nature of local CCGs’ system plans has limited the ability of the trust to align and shape strategy, related transformational plans to facilitate longer term QIPP/CIP, and relevant service developments

• In turn this has limited Trust’s ability to determine impact on workforce, and true extent of CIPs for period of plan.

• As at March 2013, CCGs have formed Compact with local NHS Trusts and local authorities to develop local health economy strategy, with Trust involvement

Slide 23


Performance 12/13 – Board Development• Board development programme has continued using external facilitator

• Topics covered include: reflections on effective board working and on results of SHA board review, including planning trust approach to increased stakeholder engagement by trust and board; also QIPP system plan, staff survey.

• Findings from BGAF self-assessment and external review being used to influence development programme.

• Reflection on effective board working led to introduction of informal bi-monthly board meetings for consideration of major strategic issues, combined with visits to services.

• Actions resulting from BGAF self-assessment and external review being undertaken and monitored via FT Programme Board. These include introduction of a code of conduct, self evaluation by all board committees plus follow up external board evaluation planned for summer 2013; board agreement of induction programme for new members.

• Chief Executive left Trust in February. Interim Chief Executive Julia Bridgewater joined the Trust on 1 April; substantive recruitment to Chief Executive post Autumn 2013.

• Director of Finance and Director of Operations left trust in Jan/ Feb respectively; roles filled with interim directors. Recruitment underway for permanent positions (interviews 23 and 24 April 2013)

• Directors undertaking personal development linked to PDPs and issues identified by BGAF and portfolio review.

Board development programme document available on request.


3. Plans for 2013/14

Eight key areas:

• Clinical Quality

• Operational performance standards

• Workforce/ OD

• Service Improvements/ Developments

• Financial Plan

• FT Application

• Board Development

• Partnership Working

Slide 25


Clinical Quality Plans 13/14 (1)A five year Quality Strategy has been developed for the Trust (approved in Oct 2012). The

strategy provides a framework to engage all services and staff in developing care which is patient

centred, safe, and effective whilst ensuring efficiency, equity and timeliness are embedded in service

improvements.

To ensure that the Trust succeeds in its aim to exceed expectations in the quality of the care and

outcomes for our patients/ services users and carers, the specific objectives have been developed at

organisational, divisional and service levels.

Specific objectives include the following key areas:

1. Pressure Ulcers

Substantial work is ongoing to achieve Ambition One of NHS Midlands and East to eliminate all

avoidable Pressure ulcers, reflected too in the Trust’s commitment in the Quality Account and wider

system responsibility. This includes increasing the numbers of the Tissue Viability Team, membership

of SHA Pressure Ulcer Collaborative, increase in training provision to staff and partners in care

homes, initiation of a helpline to encourage involvement of TVN team prior to PU developing.

2. Mortality

The Trust as a community organisation does not have HSMR or SHMI information and therefore has

implemented a Mortality group to review unexpected deaths in community hospitals, using the global

trigger tool. Zero avoidable deaths were identified. As of April 2013 we will be reviewing all deaths to

ensure learning and best practice has been implemented for end of life care. In addition we link to the

Child Death and Overview panel of the Local Children's Safeguarding Boards.

Pressure Ulcers

In seeking to achieve having no avoidable pressure ulcers (grades 2, 3 or 4), all patients at risk or who have an ulcer will have an individualised care plan. All patients will be assessed using a recognised assessment tool. The trust has implemented mandatory pressure ulcer prevention training for clinical staff and also provides training for partner organisations and carers. SSKIN has been implemented across the trust (as per Slide 12).


Clinical Quality Plans 13/14 (2)Key areas (continued)

3. Safe Care: Harm Free Programme

The Safe Care: Harm Free Programme within Shropshire and Telford and Wrekin is part of the

second wave of a national programme to improve patient safety by reducing harm caused to

patients by Falls, VTE, pressure ulcers and catheter acquired UTIs. Work will continue to be a

priority in 13/14, expanding to link with voluntary sector and other care agencies.

4. Making Every Contact Count

We aim to achieve a target of 80% of frontline staff from identified staff groups and/or settings

have appropriate skills, competences and knowledge to raise healthy lifestyle issues and offer

brief opportunistic advice and signpost/refer to appropriate services, with a particular focus on

smoking, alcohol physical activity, and obesity.

5. Seamless Care

Our goal is simply to provide a more joined up service for our patients, in schools, homes (be it

peoples’ own home or care/ residential) & our community hospitals.

We will ensure patients/ clients referred to our care in the community will have an

understanding of who to contact should they have any concerns or worries reflecting the need

to support care closer to home.

Safe Care: Harm Free This is a local health economy-wide project. It will be carried through into 13/14 and link with the Safety Thermometer CQUIN re improvement in pressure ulcer prevalence.

Slide 27


Clinical Quality Plans 13/14 (3)6. Patient Engagement & Experience

Improving the patient experience is a key objective for the Trust and is consistent with the core

ambition of NHS Midlands and East to deliver a “Patient Revolution”. The Trust aims to deliver a

better patient experience by implementing the following actions and using the feedback gained as a

measurement of our success:

• Further develop our Patient Experience and Engagement Group to oversee and manage the patient

experience work that is going on within the Trust.

•Implement the Patient Experience and Engagement Framework to bring all the differing work together

in a cohesive and clear manner.

• Use feedback from Patient Opinion, (UK's leading independent non-profit feedback platform for

health services) to drive improvements in patient experience.

• Expand implementation of the “Net Promoter” question in all relevant patient experience surveys. We

aim to ensure that 98% of our patients will recommend the Trust to their friends and family.

•Implementation of duty of candour

Quality Account

A robust, consultative approach has been undertaken by the Trust to develop its Quality Account for

2013/14. This involves seeking input from partners and stakeholders via two interactive workshops, to

agree priorities and content. This work commenced in January, with priority areas to focus on

community hospitals and outpatients, children and family services and the wider community teams.

The process has ensured the content is developed in an inclusive manner, taking into account

feedback received from the current year’s document.


Performance 13/14 – Operational Standards

Actions planned to ensure non recurrence of 12/13 performance issues

RTT (admitted) – community dental service

In the short term, the standard will be achieved using alternative providers (as per slide 11 notes).

Urgent resolution is being sought from Shrewsbury and Telford Hospitals NHS Trust so that a

sustainable solution can be put in place. A service level agreement to cover access to Theatres

and Anaesthetic teams is currently being negotiated. Commissioners have agreed through current

contract negotiations to include a review of RTT performance in monthly performance review

meetings where management across the health care system is required.

RTT (non-admitted) – community paediatrics

Standard to be achieved via continuation of 12/13 process improvements (as per slide 11)

Avoidable Grade 3 and 4 Pressure Ulcers

As per slide 26, a large amount of work is ongoing to eliminate all avoidable pressure ulcers.

Director of Nursing (or Deputy) is meeting monthly with team leaders/ clinical service managers

to discuss and determine actions and sustainable solutions.

VTE

The Trust has been compliant since Oct 2012 and performance continues to improve.

VTE Daily notes checking audit has now been rolled out to all ward managers to ensure risk assessments performed and identify areas of non compliance with follow up action for relevant medical staff.


Workforce Plan 2013-14

Planned Changes in the Trust’s Workforce : (included above)

• Loss of income from PCTs for providing joint Corporate Services.

• End of the contract for Sexual Health Services and closure of the Dana Prison.

• Increase in Health Visitors as per national priorities.

• Identified Pay Cost Improvement Programmes giving in-year savings of £227k.

Other Factors Potentially Impacting the Trust’s Workforce : (not reflected above)

• Achieving financial balance in the absence of transitional funding ahead of system change requires a total CIP of £2.5m of which £2.3m is still subject to discussions with commissioners. Any such CIP where identified and confirmed will require a reduction in employed staff. Such a value could, subject to timing, affect 80 or more full time equivalent

staff.

Sign off

• The Trust’s Workforce plan is signed off by the Chief Executive, Director of Nursing, AHPs, Quality & Workforce and the Medical Director, in line with SHA requirements.

Workforce Plan

2013-2014 FTE

Corporate

Services

Reduction

Sexual

Health

Dana

Closure

Infection

Control

Identified

CIPs

Health

Visitors

FTE

31/03/13 31/03/14

MEDICAL AND DENTAL 40.4 0.0 (2.9) 0.0 0.0 0.0 0.0 37.5of which - Medical and Dental Consultants 11.5 0.0 (1.2) 0.0 0.0 0.0 0.0 10.3QUALIFIED NURSING, MIDWIFERY AND HEALTH

VISITING STAFF 659.0 0.0 (9.7) (7.7) (3.2) 0.0 8.6 647.0SCIENTIFIC, THERAPEUTIC AND TECHNICAL

STAFF 156.6 0.0 (1.2) 0.0 0.0 (1.7) 0.0 153.7

Healthcare assistants and other support staff 133.8 0.0 (5.2) (3.8) 0.0 0.0 0.0 124.8

Managers and senior managers 53.9 (15.4) (1.2) 0.0 0.0 (1.4) 0.0 35.9

Administration and estates 320.3 (17.1) (13.2) (1.7) (0.6) (3.1) 0.0 284.6

All employed staff in post (FTE) 1,364.1 (32.5) (33.4) (13.2) (3.8) (6.2) 8.6 1,283.6


Workforce Plan 2013/14 (2)

• Roll-out of the Initial Sickness Absence Reporting (reactive early intervention by Occupational Health) pilot.

• Further work in stress awareness and prevention which includes training in stress management for staff and managers. This will be supported by a Stress and Staff Support Policy and sickness absence task and finish group whose aim will be to significantly reduce absence caused by stress within the Trust.

• Improvements to sickness data reporting by supporting Managers to enable use of ESR Self Service. Including audit and retraining as required.

• Enhancements to sickness management information including detailed sickness data breakdowns by department, sickness reasons, analysis of absence patterns and review of actions taken.

• Continuation of staff engagement initiatives in partnership with Trade Unions using a task and finish group to examine and act upon key actions from the staff survey 2012.

Slide 31


Workforce Plan 13/14 (3)Appraisals/ PDPs: Content and Completion Rate

• Drive for staff development supported by new appraisal process, and underpinned by the training implementation plan which is part of the Leadership, OD and Workforce Strategy

• Specific training is being developed with a focus on translating Trust objectives to key Divisional/ Team objectives that support Divisional Business Plans. These will also focus on the quality and patient experience. This training will be delivered to the Senior Leaders Forum.

• Delivery of staff appraisals will be a mandatory objective for all line managers from 2013/14.

• Line managers will produce a 2013/14 appraisal schedule for all direct reports. Progress to be monitored monthly at individual and team level

• Reporting of appraisal completions to be developed on ESR to individual manager level.

• Progress at team level to be monitored monthly by OD & Workforce Group and Quality and Safety Committee. Departures from the plan will be referred to the Trust Executive Team.


Service Improvements/ Developments - 13/14 (1)

Service priorities – commissioner strategy

• Both local CCGs are currently working on combined local health economy strategy, to be taken forward via Compact of local organisations to be formed. Compact envisages joint work programme including frail complex pathways, RAID, shared approach to managing demand and capacity, and implementing Francis recommendations and vulnerable children’s strategy.

• The emergence of this strategy is crucial to provide the basis of transformational plans on which the trust can shape CIP/QIPP

• Market testing of services also features

• Pending strategy, commissioners’ areas of main service focus are flagged as shown below.

• Underpinning principle is providing care where it is needed/ shifts of activity through the system.

• Urgent care/frail complex, including

-community teams

-community hospitals – recovery, assessment and diagnostics

-integrated care/flow

• Long term conditions strategy – including voluntary sector links

• Implementing CAMHS review; other specific services under discussion

• Health promotion/ illness/ prevention – client-centred approach with outcomes

Slide 33


Service Improvements/ Developments - 13/14 (2)Trust Service priorities

In support of the emergent local health economy strategy, the Trust’s priorities (for

further detailed discussion and agreement in the Compact) are as follows:

Transforming community services to support LHE strategy & deliver greater productivity, especially:

– Ludlow Community Hospital financial close and work required in the coming year on the project

– Community teams: extended/integrated to support unscheduled care / LTC – e.g. frail complex project, new pathways for admission avoidance in children’s services (wheezy child) and involvement in referral assessment system (single point of access)

– Community Hospitals: supporting greater acuity; assessment/diagnostics/ reablement

– CAMHS, community paediatrics, dental and other specific services

– Partnership with voluntary sector for community approach.

Further clarity is needed on the local health economy strategy in order for the trust to finalise overall

transformational plans (see also slides on context for financial plan for 13/14).

In addition the Trust intends to implement specific workstreams to take forward the requirements

associated with High Impact Innovation actions (refer to planning checklist for more detail).

The Trust has been discussing a number of service developments with both Shropshire and Telford

and Wrekin CCGs in line with their commissioning intentions and the Trust’s service priorities. As

agreement to these developments has not been confirmed in contract discussions at the time of

writing, they are not included here. They will be incorporated into the Plan if appropriate at a future

point.


Context for Financial Plan for 2013/14 :

Update on the Health Economy

• The local health economy would require the Trust to remain viable and capable of delivering the services needed in order to facilitate the commissioners’ intentions to drive activity from acute to community and primary care settings

• Despite building local momentum, the near term outlook is particularly challenging given the expected timing difference between strategy development and implementation of pathway change

• In the short term the Trust will need to balance the increasing short term demands and pressures on services, with the continuing need to drive efficiencies and transformation, against a backdrop of an overheating acute sector and downward pressure on tariff

• A Compact has been produced with full Trust involvement, within the workplan of the Chief Officers Group.

• Finnamore have been commissioned by the CCGs to complete work which includes understanding and aligning planning assumptions. This will include understanding activity shifts and will be a cornerstone as the health economy seeks to transform itself. The Trust is keen to work with the Compact on process and timescales

• The CCGs, LAT and SaTH have also commissioned work by ATOS relating to urgent care, including a review of services which the Trust provides and may deliver in future to reduce emergency admissions.

Slide 35


Context for Financial Plan for 2013/14 :

Update on Discussions with Commissioners

• Significant Trust CIPs were developed and submitted early in the planning cycle but commissioner feedback is that more work is required before they can be accepted

• The Trust continues to work with its main commissioners but despite increasingly close working, it is becoming less likely that internal transformation and efficiency measures will deliver quickly enough to deliver substantial in year CIP values

• The Trust recognizes its CIP responsibilities and continues to review its operations with a view to identifying further transformation and efficiency opportunities

• Given the timing issues affecting the system plan and overall local health economy strategy,2013/14 may best be taken as a transitional year in which the Trust readies itself for the full impact of system change in 2014/15.

• In practice this would allow time to embed changes and become operationally ready to deliver into the transformed system, including strengthened transformational capacity


Financial Plan for 2013/14• The Trust is planning for an FRR of 3 in 13/14 and 14/15

• Achievement of this target in 13/14 will be a significant achievement as Operating Income

before Service Developments will reduce by 10% following recent decisions regarding prison

closure (Dana); transfer of services to CSU and the sexual health tender

• Annual plan submission indicates delivery of FRR3 for 2013/14 and a planned surplus of £0.2m

• This includes £2.5m of in year CIP, of which 94% remains classified as unidentified following

commissioners’ indication that further work is required before CIPs are acceptable

• Recognising the timescale for planning and implementing proposals, it is increasingly unlikely

that CIPs will be sufficient to close the financial gap

• CIPs will be likely to generate significant redundancy costs in year, which may outweigh in year

savings and this will need further careful consideration for 13/14

• No redundancy costs have been allowed for in the above figures

Slide 37


FT Application (Plans for 13/14)

(Noting that steps below will have commenced in 12/13)

• All the following points are subject to revised trajectory being agreed with NTDA

• CCGs to publish local health economy system plans

• Trust to update Vision and strategic objectives to ensure alignment with system plans

• Trust to reassess future service development proposals and CIPs in light of system plans, for agreement with CCGs

• IBP/ LTFM to be updated

• BGAF, QGF and HDD1 (readiness review) action plans to be progressed

• Board development to continue, including B2B readiness

• Public consultation undertaken, members recruited

• Phase 2 Readiness Assessment (HDD2) completed

• B2B with NTDA, leading to approval to submit application


Board Development (Plans for 13/14)

• Substantive recruitment to Chief Executive and Executive Director vacancies; embedding of new Executive Team

• Ongoing programme of externally-facilitated development sessions, and informal bi-monthly board discussions followed by visits to services

• (Existing documented and board- agreed) induction programmes for new executive directors to be implemented

• Continued focus within board development sessions on recommendations from external BGAF assessment, including: coverage of FT requirements, regulatory regime and board and governor roles; ensuring effective board working and behaviours

• Technical topics identified for additional coverage include benchmarking data allowing comparison with other trusts, CQC compliance, and updated market assessment

• Continued implementation of package of board and committee evaluation proposals agreed in November 2012, including external board evaluation in summer 2013

• Maintenance of mandatory training for board, including business continuity and infection prevention and control

• Review of board member personal development plans for 12/13 and refresh for 13/14.

Board- agreed induction programme for new board members (separate document) available on request Slide 39


Partnership Working (Plans for 13/14)

• Ongoing implementation of stakeholder engagement plan, agreed by board in November 2012, including a targeted approach to communication and engagement with priority stakeholders

• Developing relationship and appropriate information-sharing with commissioners and other local providers

• Ongoing discussions with both local authorities about further opportunities for integrated working

• Ongoing discussions with local voluntary sector about joint working opportunities, especially in urgent care and long term conditions

• Staff engagement plan ongoing – addressing themes from staff surveys


4. Key Challenges for 13/14 (1)(Key Delivery/ Variation challenges and Trust Actions to Resolve

Community Hospital and

Community Team staffing level

benchmarking

Urgent need to establish if there

is variation from top performers

and why, to ensure ability to

provide needed acuity of high

quality care

Harm free care Ongoing Trust challenge re

pressure ulcers and VTE

compliance

Reduced staff sickness and

stress

Sickness absence above trend,

averaging 5.03% in 12/13

Improved patient experience

capture and related

improvement

Improved uptake on friends and

family test required (though not

yet mandatory for community

trusts)

Note: the challenges stated above align with Annex A improvement priorities

Slide 41


4. Key Challenges for 13/14 (2) (Organisational challenges and Trust Actions to Resolve)

• Local health economy strategy

Working in partnership with others so emergent local commissioner-led health economy strategy

provides a framework for future agreed transformational plans to shape future QIPP/CIP. Trust has

held Board with Board meetings with both local CCGs, and is contributing actively to the Chief Officers

group, led by the CCGs and with membership from all local statutory organisations, which has

developed a Compact as at March 2013 with principles for joint working and production of local health

economy strategy and agreed aligned principles for system refresh.

• Financial Outlook

13/14 and 14/15 extremely challenging – significant CIP gap given status of proposals and system plan.

Trust is committed to working in partnership with commissioners but serious concerns remain regarding scope to deliver CIP in 13/14 against increasing demands; from a broader system perspective there would be value in seeing 13/14 as a year in which the Trust embeds service improvements ahead of seeing the fuller impacts of system redesign implementation in 14/15.

• Strengthening commissioner and stakeholder relationships

Ongoing programme of board to board and other meetings, underpinned by implementation of Trust

stakeholder engagement and communications plan (November 2012) covering all major Stakeholders.

Trust stakeholder engagement plan available as separate document


4. Key Challenges for 13/14 (3)(Organisational challenges and Trust Actions to Resolve)

• Executive team capacity for a period given loss of key directors

Interim Directors in place as at February 2013; substantive recruitment to posts already

underway with interviews set for early April; substantive Chief Executive recruitment Autumn 2013.

• Sustainability - Impact of lost business, and risk of further loss of business from commissioners’ market testing strategy

Alignment with emergent commissioner strategy and further strategic discussions with

commissioners; priority given to addressing service issues where services are under

review including CAMHS and community paediatrics; implementation of marketing

strategy (agreed January 2012)

• Staff engagement- maintaining positive staff engagement and reducing sickness absence

See Workforce and OD section

Slide 43


NHS Trust 2013/14 improvement priorities template Annex A

No. Improvement Priority Improvement Plan

1 Review and address community

hospital staffing levels to meet

health economy needs for

higher acuity patients

•Analyse dependency data collection from November

•Carry out gap analysis by May 2013

•Reported through operational Q&S group and formal paper

to executives.

•Discuss outcomes and recommendations with

commissioners end of May 2013

•Lead responsibility Deputy Directors of Nursing and

Operations

2 Review and address wider

community team staffing levels

to meet health economy needs

for higher acuity patients

•Implement dependency tool in February systematically

across teams

•Review data and potential impact on skill mix and staffing

requirements by May 2013

•Reported through operational Q&S group and formal paper

to executives.

•Discuss outcomes and recommendations with

commissioners

•Lead responsibility Deputy Directors of Nursing and

Operations

3 Ongoing work with local health

economy partners to reduce

harm for all patients

•Continue progress via Harm Free Care project board and

its 5 task and finish groups (pressure ulcers, VTE, catheter

acquired UTIs, falls, nutrition and hydration)- Monthly

review of progress and link to CQUINs

•Increase link with local authorities and care agencies and

wider public engagement by May 2013

•Ensure all aspects of work sustainable beyond life of

groups review end of September 2013

•Lead responsibility Directors of Nursing /AHPs


NHS Trust 2013/14 improvement priorities template Annex A

No. Improvement Priority Improvement Plan

4 Reduce staff sickness and

stress

•Systematic work across all staff groups addressing

underlying issues including reviewing pockets of

organisational stress - monthly review at OD and Workforce

group

•See also workforce and OD section for detail

•Lead: Deputy director of HR/Workforce/OD and Deputy

Director of Operations

5 Improved capture of patient

experience information and

demonstrate related quality

improvements

•Continue development of use of friends and family test

(though not statutory for community trusts) - CQUIN 2013/14

•Develop approaches with partners to collecting patient

experience data collaboratively across care pathways March

2014

•Implement real time experience capture across our

disparate and dispersed services March 2014

•Lead: Deputy Director of Nursing & Quality

Slide 45

NHS Trust 2013/14 development priorities template

No. Development Priority

1 Development of in-house business skills to reduce reliance on external

support, including business development and tender preparationsPotential TDA support: facilitation of networking and access to good practice

expertise in other organisations; support from NHS Leadership Academy and new

improvement body for transformational change at the acute/community interface

2 Further benchmarking amongst Community Trusts eg to establish a

community quality dashboard – potential for work to be led by aspirant

Community Foundation Trust groupPotential TDA support: sponsorship of aspirant Community FT Trust work

3 Effective use of Service Line Reporting Potential TDA support: access to expertise and established good practice in similar

services, especially in making best use of SLR and maximizing connections with

tariffs and contracting approaches

4 Board evaluation and development, particularly linked to best practice re

unitary board and new skills assessment at interview.Potential TDA support: facilitate access to learning from best practice elsewhere

5 Collaborative work across the health economy for system wide solutions

to challenging financial position.

Potential TDA support: facilitate access to learning from best practice elsewhere

Annex B

Meeting Date: 18 July 2013 - Shropshire Community Health ... · 2.3 Transfer of Adult Learning...

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