Upload
others
View
3
Download
0
Embed Size (px)
Citation preview
1
Royal Berkshire NHS Foundation Trust
Operational Plan 2016/17
18 April 2016
Version for external publication
2
1 Introduction & Context
Introducing the Trust
The Trust impacts directly on approximately half a million patients each year through the provision of
high quality acute medical and surgical services to the local communities. The Trust also provides
specialist services to a population of one million across Berkshire and its borders. The Trust provides
services from the following sites:
• Royal Berkshire Hospital.
• The Prince Charles Eye Unit, Windsor, provides eye services to the patients of East Berkshire.
• Dialysis services at a dedicated unit in Windsor.
• West Berkshire Community Hospital - day surgery unit and the acute outpatients department.
• Royal Berkshire Bracknell Healthspace – cancer, renal and outpatient services.
• Townland’s Hospital, Henley – outpatient services.
The geographical disbursement of these sites affords the opportunity of the patient to be treated closer
to home. In addition the Trust provides services from a number of other sites in the community and
directly provides some community services.
The Trust is a specialist centre for cancer, bariatric care, heart attack and stroke, with a designated
Hyper Acute Stroke Unit. In addition the Trust provides specialist care as part of a network in
neonatology, interventional radiology and trauma. The Trust also provides services which may not be
found in every hospital including spinal surgery.
The population served has a diverse range of needs. Whilst some areas are relatively affluent there are
pockets of deprivation with some areas in South Reading being ranked amongst the 20% most deprived
areas in the country. Population growth is expected, including in Wokingham and Bracknell, with
migration patterns suggesting that there are a number of older people moving into the Wokingham
area. Wokingham has a higher prevalence of cancer and asthma; South Reading has higher rates of
deaths from cardiovascular and respiratory disease, North and West Reading has a higher prevalence of
cancer and depression. People in Slough have higher levels of diabetes whilst those in Maidenhead,
Windsor and Ascot have a higher prevalence of cardiovascular disease and cancer.
2015/16 Achievements
The challenge that the Trust faced in 2015/16 was the need to deliver significant savings whilst ensuring
that it meets the standards for quality of care that our patients deserve. Responding to operational
performance improvement challenges and meeting rising demand put significant pressure on pay and
support costs. This has meant that, whilst the Trust continues to be proud of the quality of care it has
delivered, it has had to put robust focus on its short term financial recovery programme to ensure
maintenance of a strong cash position and delivery of cost improvement programme (CIPs) and
reduction in agency spend to target. The Operational Plan for 2016/17 will continue to build on some
notable developments in 2015/16:
• Strong cash controls maintained as evidenced by month end cash position exceeding plan.
3
• The Trust forecasts that it will meet its Cost Improvement Programme (CiP) target of £16m.
• Medical productivity has improved, with job planning completed for over 99% of consultants
and tighter leave policies introduced. A new electronic system to support revalidation job
planning and rotas has been introduced.
• Two key projects in maternity and ophthalmology have been delivered as per plan, with the
unannounced inspection of maternity by the CQC evidencing success.
• The Trust has been working with colleagues in other organisations in progressing a Berkshire
and Surrey Pathology Service serving 5 hospitals.
• The Trust has been working closely with other health economy stakeholders to position the
system to be in a position to deliver in the new environment via a shadow Accountable Care
System (ACS).
• Improving links with GP practices and primary care to better understand issues, and to identify
key themes and trends.
• Good progress has been made on our quality priorities such as incident reporting, delivery of the
CQC action plan and ensuring safe staffing. The Trust is making additional efforts to improve
those areas that have not seen sufficient progress including medical records and improving our
administration systems.
• The Trust continues to demonstrate an on-going excellent patient experience through the
friends and family test.
The Royal Berkshire NHS Foundation Trust’s Operational Plan for 2016/17 explains how the Trust
intends to achieve balance between the provision of high quality services that comply with access
targets and also meet our financial control targets. This will bring us to a position of improved short
term financial sustainability by the end of 2016/17 and supports the development of system-wide long
term planning.
This plan provides assurance that the Trust has addressed the key aspects of activity, quality, finance
and workforce planning. The plan explains how the Trust is encouraging local representation through
our Governors and membership. The Trust has also set out its involvement in the development of the
system –wide Sustainability and Transformation Plan (STP), and the key actions that will be taken to
progress this in the coming months.
On-Going Challenges
The Trust continues to deliver but against a context of having an ageing estate, with little room for
significant expansion at the Royal Berkshire Hospital, with an ICU that is small for the population it
services. The Trust faces competition in its immediate locality from three independent sector providers
in a number of services which has seen work transfer but leaves the Trust with substantially the same
cost structure. The area the Trust serves is mostly affluent with associated higher costs of living than in
some areas of the country. This is believed to underpin some of the issues that the Trust experiences
with regards to being able to attract and retain staff.
4
2 Sustainability and Transformation Plan (STP)
System-wide Planning
The Trust is working closely with system partners in developing new models of care both via the
Sustainability and Transformation Plan (STP) - Buckinghamshire, Oxfordshire and Berkshire West
footprint - and the locally established Accountable Care System (ACS) of Berkshire West. The STP
footprint describes a geographic area that has been mandated to work together to resolve issues across
the area to close the gaps in health and wellbeing, care and quality, finance and efficiency. The STP is a
plan that is based on place (this wider system) and not one based on organisation boundaries (such as
this plan). The footprint has only recently been confirmed and therefore work is at an early stage of
maturity. The Trust recognises the principle of subsidiarity, and the need to plan at different levels, and
continues to support the continued development the Berkshire West ACS. The operational plan that has
been developed is in line with the principles of the ACS and the principles underlying the STP. The Trust
has engaged with the wider footprint and continues to meet with partners in supporting the creation of
Berkshire West ACS.
The ACS is a more formal local arrangement established to facilitate the Trust, Berkshire Healthcare NHS
Foundation Trust and the local commissioners to working together. The ACS is a collective enterprise
that unites its members and binds them to the goals of the health system as a whole. This will help
system partners hold each other collectively to account for delivering the necessary transformation of
services and in getting the best value for money for patients and taxpayers. A Memorandum of
Understanding has been drafted to underpin this and further development by respective organisation
boards is expected The development of the ACS is underpinned by a clear and shared objective to
address the challenges articulated by the Five Year Forward View by ensuring that the Trust:
• increases the emphasis on primary prevention, health and well-being;
• improves quality of care through better outcomes and experience for patients and achieving
constitutional standards; and
• operates a financially sustainable system .
The development of the STP footprint and ACS will have a number of critical impacts in 2016/17 on the
Trust’s Operational Plan. The Trust will need to be more focussed on the development of clinical
decision-making and service developments which drive proactive management of care and provision of
care in the most effective settings. The Trust believes that this will underpin the development of a
Berkshire West system strategy, which in turn will support the STP development. In 2016/17, the
Berkshire West strategy will primarily focus on development of the frail elderly pathway and exploring
pathway changes and trialling new payment mechanisms beginning with dermatology and respiratory.
Our lead commissioner has demonstrated a clear commitment to move towards a payment system that
moves resources to the optimal part of the system that rewards providers appropriately; aligns
incentives and risks; and helps all organisations achieve long term financial balance by unlocking
efficiencies. This will help ensure that negative incentives to pursue the most profitable market share
5
are removed. However, whilst a number of different mechanisms need to be considered, it is at a very
early stage and no revised payment mechanisms have been agreed. The Trust will be working with the
commissioners and other providers to ensure that there is robust financial analysis to support this.
As a system, we are also prioritising the establishment of a governance structure reflective of a unified
leadership team, with delegated powers from the constituent organisations. This is the critical enabling
milestone as this will allow us to release back office efficiencies through closer joint working. This will
allow the development of a dedicated work stream exploring how IT, HR, finance, payroll,
communications and facilities management functions can be streamlined across the constituent
organisations. This work has yet to be established but will look to find the best solution for the local
area.
The timeline for 2016/17 identifies the following key actions:
• Stabilise the financial position with no further deterioration from agreed control totals across
the system
• Secure operational performance
• Develop the five year Sustainability and Transformation Plan
• Develop the five year financial plan for Berkshire West
• Introduce some Gain and Loss sharing within the system across all organisations
• Begin the proposed pathway changes, trialling new payment mechanisms
• Review economies of scale and commence rationalisation of back office functions Develop a
shared approach to system enablers
Impact on our Operational Plan
The vision of the local health system is for healthcare organisations of Berkshire West to plan and act
cooperatively on behalf of our population to deliver the best possible experience and outcomes within
our available resources. The Trust will enable this through organising around the needs of the
population rather than planning at an organisational level. The Trust’s own vision has been formed
directly in alignment with that of partners, namely to ensure that patients are treated seamlessly across
organisation boundaries and that the hospital will always deliver both excellent care along with
improved health outcomes for the population. The Trust’s strategic aims are being developed to focus
delivery of this vision through:
Quality care, centred on meeting the patients’ expectations and ensuring that they live longer and
healthier.
• We will improve how we listen to and learn from patient experiences and involve patient
leaders in our services.
• We will prioritise continuous quality improvement, focussing on ensuring that we reduce harm
with a strong safety culture
6
• We will focus quality improvement initiatives on the patient outcomes and our strategic
initiatives on ensuring the achievement of better health outcomes for the population, with our
partners.
• Our behaviours will be aligned with Trust Values, aligned to the NHS Constitution to drive quality
• We will be a learning organisation with comprehensive structures of disseminating
improvement across all staff.
Achieving the right balance of delivering quality within all available resources, to ensure we invest for
the future.
• There will be an equal consideration of quality, efficiency and cost in our business planning and
prioritising processes, demonstrating good stewardship of taxpayers’ money.
• The consideration of clinical risks and financial viability will be integrated.
• Our commitment to the pursuit of optimal productivity and efficiency will be supported by
transparent decision-making processes and prioritisation.
Productive partnerships with patients, staff, partners and commissioners that deliver improved
outcomes for the public.
• We will work as a system leader to support change and transformation to meet NHS regional
and local goals.
• All staff will model and demonstrate leadership behaviours that support integration and system
working.
• Identify system KPIs that show real long term benefits for the population and integrate these
into our Trust objectives.
A positive culture that supports and develops our staff to always strive for excellence.
• All staff will have an effective and structured appraisals and performance development plan.
• Succession planning and talent mapping will be put in place, supported by a programme of
training and development that is centred on our values and our objectives.
• Outcome-focussed health and wellbeing and equality and diversity programmes will be
refreshed to target areas of need.
2016/17 Trust Objectives
The Trust continues to build upon the strategic goals developed as part of last year’s Strategic Roadmap.
As part of the on-going development the Roadmap, the Board has reviewed the Corporate Objectives
for 2016/17. The Objectives have been based on the Board’s analysis of performance against the
previous year; consideration of the key financial, quality and operational performance challenges; and
the reflection of the 2016/17 NHS England 9 ‘must dos’ as articulated in the Five Year Forward View:
1. Develop a high quality and agreed STP, and determine the most locally critical milestones
for accelerating progress in 2016/17 towards achieving the triple aim as set out in the
Forward View.
7
2. Return the system to aggregate financial balance. This includes secondary care providers
delivering efficiency savings through actively engaging with the Lord Carter provider
productivity work programme and complying with the maximum total agency spend and
hourly rates set out by NHS Improvement.
3. Develop and implement a local plan to address the sustainability and quality of general
practice, including workforce and workload issues.
4. Get back on track with access standards for A&E and ambulance waits, ensuring more than
95 per cent of patients wait no more than four hours in A&E, and that all ambulance trusts
respond to 75 per cent of Category A calls within eight minutes.
5. Improvement against the standard that more than 92 per cent of patients on non-
emergency pathways wait no more than 18 weeks from referral to treatment.
6. Deliver the cancer waiting standards, including by securing adequate diagnostic capacity;
and make progress in improving one-year survival rates; and reducing the proportion of
cancers diagnosed following an emergency admission.
7. Achieve and maintain the two new mental health access standards.
8. Deliver actions set out in local plans to transform care for people with learning disabilities.
9. Develop and implement an affordable plan to make improvements in quality particularly for
organisations in special measures.
The 2016/17 Corporate Objectives are set out below mapped to the Trust’s Strategic Goals. They will
form the basis of the Executive and Senior Management appraisal process and objective setting for next
year and subsequently will be reflected in individual appraisal documentation.
8
9
3 Quality
Quality Improvement
The Trust-wide Quality Improvement Strategy is jointly led by the Director of Nursing and the Medical
Director and focuses on clinical effectiveness, patient experience, patient safety and culture. This
strategy is reviewed annually and 2016/17 will be the third year of our current strategy which continues
to demonstrate achievement. The improvement approach of the Trust is based on a combination of
project management and quality improvement methodologies. There is a clear governance structure in
place through the Trust Improvement Programme Board chaired by the Chief Operating Officer and
jointly managed with the Director of Finance to ensure that the right balance is achieved between
quality and finance. This Programme Board reports into Senior Management Team and Board.
The Trust has developed a Clinical Audit and Quality Improvement annual programme based on an
analysis of patient safety and experience data from 2015-16 and aligned to the Trust’s key quality
priorities for 2016-17. The completion of this programme will be monitored through the Trust’s Clinical
Outcomes and Effectiveness Committee chaired by the Medical Director. Throughout the year
additional quality improvement projects may be identified in response to specific quality issues and
service needs; these will be evaluated and approved by the clinical leads and managed by the clinical
audit and improvement facilitators within the Quality Governance Team.
In addition, root cause analysis (RCA) investigations are completed for all identified ‘Serious Incidents
Requiring Investigation’ (SIRIs) and incidents for which significant learning has been identified. From
these investigations robust action plans for improvement are developed and learning shared across the
organisation to mitigate the patient safety risks highlighted. Regular thematic reporting from SIRIs goes
to the Trust Quality Assurance and Learning Committee for oversight and wider dissemination of
learning and improvements made. The Quality Assurance & Learning Committee is primary committee
for providing assurance to the Board (via the Clinical Governance Committee) of clinical quality across
the organisation.
Quality Priorities and Risks for 2016/17
The Trust has identified its quality priorities for 2016/17 based on patient and staff feedback, on-going
work streams from 2015-16, and key national targets. Each priority has an identified lead and action
plan for improvement which will be monitored throughout the year by the Quality Assurance and
Learning Committee.
• Staffing: substantive nursing, midwifery and medical vacancies Ensuring our hospital is staffed
with the appropriate number and skill mix of clinical professionals is vital to the delivery of
quality care and keeping patients safe from avoidable harm. Vacancy rates have been a
challenge across all staff groups, in particular midwifery and nursing. The Trust has an active
strategy for recruitment and retention which has included: re-launch of the ‘refer a friend’
scheme; use of social media for recruitment; overseas nursing recruitment campaigns to
10
Portugal and Italy; recruitment open days held for nursing and midwifery; and recent leavers
written to and encouraged to return. In addition we have incentivised our student nurses to
stay with the Trust on qualification by offering bespoke rotation programmes and support with
interview techniques and practice. In 2016-17 we will continue our recruitment and retention
campaign through recruitment open days; offering ‘Golden Hello’ payments to new staff in
orthopaedics and elderly care; undertaking further overseas recruitment campaigns; promoting
our relocation package to attract those based further afield; and offering a skills development
programme for nurses.
• The timely identification and treatment of sepsis. Sepsis has been high on the Trust’s agenda
for nearly 10 years now, and an on-going collaborative, trust wide, multi-professional approach
has continued to transform our improvement capability, capacity and resilience in trying to
make a significant difference to those patients with a diagnosis of sepsis. Our learning and
collaboration extended across the local health economy, where we are now working together
across primary, secondary and community care using a common sepsis language and
methodologies such as NEWS and sepsis screening tools. This has been collaborative team
working across a wide range of work streams all resulting in the aggregation of marginal
improvement gains across the range of different drivers. However, we recognise there is still
more work to be done. We have benchmarked ourselves against recently published national
guidance and will be implementing actions to ensure all the recommendations are solidly
embedded into our daily practice. Our work will include the “front door” admissions, but also
focus on patients developing sepsis on the wards.
• Reducing waiting times to ensure treatment is received at the right time for patients with
cancer. Further discussion of this may be seen in the activity section. The Trust has been
working with the IST to improve cancer services and has redesigned pathways and escalation
triggers. Additional staffing has been agreed to support the cancer pathway and one stop
services in a range of services have been developed. Capacity and demand work is on-going and
improved performance is targeted in 2016/17.
• Improving the availability and quality of medical records. This was a quality priority for 2015-16
which the Trust was not fully able to realise. The Trust has already automated requests of
inpatient admission, improved retrieval processes and introduced monthly audits. In 2016/17
the Trust will deliver training to all clinical and administrative staff, reduce temporary records
through tighter controls, redesigning the Health Records department – including RFID tagging,
and heightened audits.
• Improving antimicrobial stewardship. Antimicrobial resistance has risen significantly over the
last 40 years which poses a serious risk to public health. Inappropriate and overuse of
antimicrobials is a key driver. Improving antimicrobial stewardship is therefore an important
national priority for clinical effectiveness and safety. The Trust has a programme of education
and training on antibiotic prescribing and stewardship. This is supported by a new ‘app’ for
mobile devices to access antibiotic clinical guidelines for prescribers on the wards. Our
improvement programme for 2016-17 includes developing a local antibiotic consumption vs.
11
resistance monitoring system; greater antibiotic auditing and real-time feedback to prescribers;
and improving turnover times for microbiology testing to support the acute care pathway.
• Improving the Trust’s administration systems. In 2015 the Trust restructured the administrative
teams into 14 Clinical Administrative Teams. The programme for 2016-17 encompasses
improvement work streams focussing on telephony, estates, staffing and recruitment,
technology, information and training.
• Improving the care of patients with dementia and support for carers. The Trust has undertaken
much work on its elderly care wards in order to improve the care of patients with dementia
including the introduction of colour-themed wards; improvements to flooring; a cinema room;
and distraction therapy. In addition, a Trust-wide dementia training programme for staff is in
place and the Trust is ensuring all relevant staff have this training. Links have been established
and will continue to be developed with the Alzheimer’s Society who regularly visit ward areas in
order to provide expert support for carers of dementia patients. Additional planned
improvements for carers include open visiting hours, improved communication and
collaborative working, and greater involvement in the discharge process. A Dementia Strategy is
in development which will provide a framework for the continuing improvement work.
The above priorities have been developed by reviewing progress against last year’s objectives, reviewing
themes that have arisen from internal quality indicators such as incidents, complaints, clinical audit and
consultation with key stakeholders. In order to capture the patient’s perspective a conference was held
to develop suggestions and the Trust also consulted with its Governors in finalising these choices. All
staff were given the opportunity to give suggestions and vote for the quality priorities. The long-list of
quality objectives were also shared with Commissioners, Healthwatch and Health and Wellbeing Boards.
Therefore, given the way that the priorities have been developed they are designed to address some of
the key risks that the Trust faces.
Seven Day working
In addition the Trust has a specific project implementing ‘seven day services’ as part of the Trust
Improvement Programme. The scope of this programme is to identify and implement measures to
ensure compliance against the four priority standards next year (time to first consultant review,
diagnostics, intervention/key services, ongoing review). The initial phase focuses on establishing the
Trust’s position and outlining the plan for achieving the standard. The programme will include actions to
ensure improvements against the remaining six standards as per an agreed trajectory with our CCG at
the end of quarter 1 in 2016/17. The seven day services project is in place with a project plan, project
team and milestones to enable the achievement of the service development and improvement plan. The
seven day services programme includes representation from the Head of Contracting, Head of Access
and Performance, Operational and Clinical staff. The programme has an executive lead, the Chief
Operating Officer and the Trust is in the process of appointing a new clinical lead to drive forward the
actions in 2016/17. This project is supported by the PMO with monitoring of actions through the Trust
Improvement Programme Board each month.
12
Royal Berkshire participated in the national audit in August 2015 which identified that the Trust was
compliant with standards 5 and 6 and was compliant in 4 out of 10 areas against standard 2 and
compliant in 6 out of 12 areas against standard 8. In 2016/17, the Trust’s 7 day services programme
looks at the measures required to improve compliance in these priority areas and the implementation of
improvements agreed in the Service Development and Improvement Plan in the standard contract with
the CCG. This plan includes actions to progress the following four priority standards next year:
1. Standard 2: Time to Consultant Review. This was a CQUIN in 2014/15 for the Trust and the key
areas for development at the moment are Cardiology and Surgery. In both areas an action plan
to address non-compliance will be taken forward in 2016/17. A trajectory for improvement will
be agreed with the CCG by the end of quarter one with delivery against the trajectory being
monitored through the Trust Improvement Board and contract meetings.
2. Standard 5: Diagnostics – the Trust was found to be compliant in August 2015. In 2016 as per
agreement with the CCG the Trust will carry out an audit for plain x-ray and echocardiograms
3. Standard 6: Intervention and key services – the Trust is compliant with this standard and no
further action is anticipated.
4. Standard 8: On-going review – Royal Berkshire will complete a self-assessed baseline based on
the results of the NHS England audit. Following this audit, a trajectory will be agreed for key
specialities and actions implemented to meet the trajectory by quarter four.
The Service Development and Improvement Plan agreed with the CCGs, also covers the other 6 clinical
standards and progress against each of these standards will be assessed each quarter. As agreed with
the CCGs, the Trust will seek to achieve compliance, or make progress towards it, within the current
resources and financial envelope. The seven day services programme will seek to baseline compliance in
the first quarter; develop the action plan for improvement in quarter 2; and implement the actions in
line with the contract agreed with the CCG.
Monitoring and Quality Impact Assessment processes
The Board receive an integrated performance report covering safety, experience, access, clinical
measures, workforce and finance, supported by a suite of exception reports as required. Performance
issues are identified and appropriate actions to be taken which are then logged. These action points are
developed and Board sub-committees are used to further explore key issues and to help achieve
resolution. Items sent by the Board to the sub-committee will be followed up in subsequent Board
meetings until resolved. A comprehensive governance process, including an assurance and escalation
framework exists to support the Board underpinned by a hierarchy of committees.
All QIPP projects (cost and quality improvement) are identified through a series of workshops with the
Care Groups and corporate functions, which include representation from clinical and non-clinical staff.
The impact on safety, outcomes, patients and staff experience is assessed during the initial identification
of projects and the subsequent QIPP programme is signed off by the Trust Improvement Programme
Board, Finance and Resources Committee, Senior Management Team and then the Board.
13
Quality Impact assessments (QIA) are completed for all QIPP projects, by the project lead or quality
improvement lead, supported by the PMO lead. This process allows the simultaneous consideration of
clinical risk and financial viability. The areas of quality that are addressed and scored for impact and
likelihood are: Duty of Quality; Patient Experience; Patient Safety; Staff Safety; Education; Clinical
Effectiveness; Prevention; Productivity and Innovation. The Medical Director and Director of Nursing are
informed weekly of all QIAs that have been submitted. Escalated QIAs are reviewed by the Trust
Improvement Programme Board to agree which of 4 actions to take and the Project Lead is informed of
how to proceed, with the risk rating being adjusted accordingly. Post-project QIAs are completed for any
projects with escalated QIAs and approved by the Trust Improvement Programme Board, six months
after implementation of the project.
Well-Led Framework
Significant progress has been made in relation to implementing action plans to embed improvement in
relation to the Well-Led elements. The most notable areas of progress include:
• Strategic Planning: Systematic and system-wide service and strategic planning processes are in
place and, with a dedicated focus on strategy by the Board, the Trust has developed a clear
vision and objectives for 2016/17 aligned to that of partners. This has been supported by robust
progress against 2015/16 objectives.
• Risk Management: The Trust has addressed identified areas of weakness across risk
management processes and roles. This has included establishment of improved Board and
Corporate process including embedding of changes to Executive risk portfolios; the refresh of
the Board Assurance & Escalation Framework; a significantly revised Corporate Risk Register;
and improvement to more granular processes such as utilisation of the Datix risk management
modules.
• Culture & Workforce: With the appointment of a new Chair, a Chief Operating Officer and
delivery of an enhanced Board development programme, the Board of the Trust has the
experience, capacity and capability to ensure that a system strategy can be delivered. Reviews
and changes to senior roles, portfolios and governance structures are complete with a strong
leadership structure in place.
• Information management: Progress has been made in the development of Board performance
and exception reports. The effectiveness and integration of reporting and decision-making is
much improved as has Board challenge of performance and holding management to account.
The Trust has received its external assessment against the Well Led Framework on 31 March 2016. In
response to that, during 2016/17 the Trust will be focused on developing the following to further
improve our capability regarding the Well Led Framework:
• Establishment of a clinically-led service strategy that is fully aligned with commissioner and
system intentions in relation to development of the STP and the development of new models of
care.
14
• There is further progress needed to ensure that risk management processes have been cascaded
effectively down to ward level via Care Group risk registers and that the clinical audit strategy is
fully reflective of risks to the Trust’s core objectives.
• There is additional work to be done in developing a more systematic approach to delivering a
corporate quality culture that is recognised equally across the organisation. A key work stream
will be pursued in 2016/17 around our organisational development, which has previously been
constrained by capacity, including our values and behaviours, the effective impact of staff
engagement impact and the effectiveness of our leadership and management.
• The Trust will deliver enhanced Care Group performance reports (and ward reporting) aligned to
Board reporting and to Trust objectives. This will be supported by an improved Performance
Management Framework. Performance reviews along pathways (via Service Line Management)
and the delivery of a significant element of the data assurance programme will deliver enhanced
information systems to support Trust and LHE system requirements.
Membership and elections
The Trust has public governors representing five local geographic areas, as well as volunteer, staff and
partner governors. The Trust has a number of vacancies for governors and will be looking to hold
elections this year for eight seats. In order to facilitate this process the Trust and its governors have
been raising their profile with the membership through a number of methods including having a session
for people to meet their Governors in all membership meetings. Proposed dates for events between the
membership and the Governors have been circulated to the Governors. The Trust is currently exploring
having an open day to generate greater membership attendance.
In 2015/16 the membership meetings and focus groups have been oversubscribed and these meetings
have been used as an opportunity to encourage people to develop their relationship with the Trust by
encouraging them to become members. In addition the Trust seeks to encourage people to stand for
Governor through the Trust's Pulse magazine. Where there has been an under-representation of the
population we have served the Trust has sought to work with Governors to help address this issue and
has identified possible alternative ways of recruitment, for instance the Trust is currently assessing the
opportunity to engage with university students.
To help the Governors fulfil their role the Trust has strengthened its induction programme and sought to
develop them through the committees with which they engage. In addition the Governors are sent the
NHS providers newsletter.
15
4 Activity Planning
Activity Planning Process
In setting the draft 2016/17 activity plan, the Trust and the CCGs are following an agreed process to
ensure affordability. A projection for full year outturn was used to form a baseline of activity and
analysed in conjunction with seasonal variation, anticipated population growth, full year impact of
agreed business cases for service development and repatriation of activity. This analysis forms the basis
of the Trust’s growth assumptions. The Trust is in the process of concluding its negotiations with
commissioners and whilst optimistic that this will reach an agreed conclusion, cannot rule out the need
for arbitration.
The Trust continues to build on capacity and demand analysis undertaken during 15/16, utilising the
expertise and tools made available through support from the Intensive Support Team (IST) and FourEyes
consultancy. A specific piece of modelling identified through the Trust Cancer Action Plan has been
commissioned, with external insight and support being provided by the IST to model both sustainable
management of demand and improvement in the cancer access and treatment standards. The outputs
from these models and projected levels of activity are being discussed with commissioners in parallel to
the 16/17 contractual and activity negotiations to ensure agreed levels of work are realistic, achievable
and support recovery to compliance where applicable. Final activity levels are subject to negotiation
with our commissioners.
Growth varies by different services and methods of presentation but includes a base level growth based
on changes in population size and profile. Emergency Department attendance has been agreed with
commissioners and is reflective of an on-going trend of increase demand, uplifted as a result of Q4
attendance being significantly higher than previous years. And the high level outcome of the activity
planning can be seen in the figures shown below.
Growth
Type 2015/16 2016/17 Vol %
Emergency Department Attendance (A&E) 116,882 121,612 4,730 4.0%
Outpatient Attendances (incl OPPROCs) 565,355 586,900 21,545 3.8%
Non-Elective Activity (incl Obs NELNE) 54,629 56,023 1,394 2.6%
Elective Activity 47,912 50,956 3,044 6.4%
Final activity levels are subject to on-going negotiation with our commissioners. In particular the Trust is
awaiting details of the Commissioner QIPPs and their potential impact on Trust activity levels. It is noted
that under the National Contract the impact of Commissioner QIPPs remains at their risk as the Trust will
get paid for the activity undertaken. Every effort is being made to arrive at signed contracts as soon as
possible.
16
Changing Market Conditions
2015/16 has seen continued growth in attendance at the Emergency Department, with attendances in
January and February being very high in comparison to the same period in the previous year. At the
same time the Trust has seen a substantial increase in non-elective admissions in comparison to the
previous year.
In elective services the picture is more mixed but as can be seen from the above diagram the Trust’s
market share of elective procedures overall has been declining since 2011. Whilst the picture varies, this
downward market share can be seen in the diagram below for Orthopaedic procedures.
In outpatients some services such as ENT have seen increasing new attendances in recent years.
Gynaecology has seen increased numbers of new attendances since December 2012 but a decline in the
market share from our most local CCGs. Cardiology has seen growth in new attendances and cardiac
procedures undertaken. Orthopaedics in addition to its declining elective market has seen a decline in
its share for new outpatients. This decline in Orthopaedics has been mirrored by an increase in activity
and market share for an independent sector provider.
17
Capacity
Negotiations between the Trust and Commissioners are underway with a view to efficiently using local
resources to deliver activity levels together with utilising local independent sector resources where
current activity level demands. The Trust is currently supported by the independent sector in the
delivery of a number of diagnostic modalities including endoscopy, diagnostic breast services and
elements of radiology. These agreements have been in place through 15/16 and the Trust expects to
continue in this format.
As part of the Trust-wide development plans we continue to pursue ways of increasing internal
efficiency and maximise the use of Trust capacity. Where gaps are identified through capacity analysis
options appraisals are being developed to define sensible and efficient solutions to meet demand within
Trust services and in collaboration with the independent sector. It should be noted, however, that
identifying sufficient capacity for endoscopy is a continuing unresolved risk for two reasons: firstly there
are significant recruitment difficulties; and secondly there are limited options for suitably accredited
additional capacity in the independent sector or from other local hospitals. Demand and capacity work
will also be being progressed, with commissioners, regarding capacity for other diagnostics (e.g.
Radiology) given the increased need for improved access to smooth through patient pathways.
Operational standards
Whilst activity plans are under negotiation with our commissioners the Trust has factored in on-going
recovery plans where key performance standards are not being met. 2015/16 has seen significant
internal and external interrogation of the Trust’s cancer performance, resulting in thorough analysis of
specialty and sub-specialty pathways and management processes. A detailed recovery action plan has
been developed detailing needs to provide efficient and maintainable cancer services to our patients
and service users. In order to assure delivery of these improvements a number of action groups have
been created to ensure system wide accountability, clinical engagement and realisation of plans. To
support delivery of these plans, improvement trajectories have been developed and discussed at length
with commissioners, and are in the final stages of interrogation.
There have been significant improvements in the Trust’s ability to recover what is recognised to be a
national issue within Dermatology. Sustainability plans are in progress with the Trust expecting a 16/17
Q1 recovery of the Two Week Wait standard. The 62 day standard remains a significant challenge to the
Trust and requires changes to local processes, the ability to apply pathways in a timely fashion, and
resourcing clinical service to a level that enables highly efficient pathways. As a result of in depth
analysis in to sustainability improvements and availability/feasibility of additional capacity the Trust
projects a 16/17 Q3 recovery of the 62 day standard and this is currently being discussed with
commissioners.
Sustainable performance in the Referral to Treatment (RTT) incomplete standard, one of the key access
targets for the Trust, remains a high priority and is being factored in to the planning
negotiations. 2015/16 provided a challenge to accommodate and respond to national rule changes
enabling the Trust to concentrate on its pathways as a whole. This work has prompted a programme of
18
work to streamline its reporting and data capture processes, to increase the level of efficiency and
visibility of patient pathways across the Trust and to optimise the tools at our disposal. All areas of
activity supporting the delivery of efficient elective services are in scope of these discussions and specific
plans are being developed through early 16/17 with an expectation to realise change throughout the
year
The Trust has included seasonal variance in Emergency Department demand to identify required
escalation resource similar to 2015/16 winter pressures support. Due to predicted increases in ED
demand in the region of 4% (circa 5,000 attendances over the year) in a department that is already over
stretched the Trust will be expected to maintain similar performance to 15/16 and strive for a year end
compliant position with improvement on 2015/16 unlikely. Sustained performance in ED will need to be
realised through efficiency gains in patient pathways and greater collaboration with primary and social
care providers to support the wider health economy in accessing care within the community setting.
Where standards are being achieved activity planning will factor in expected growth and any
adjustments/planned changes to services over 2015/16 outturn.
Commissioner QiPPs
Notwithstanding the actions undertaken between the Trust and Commissioners we have continued to
see on-going growth in activity, particularly non-elective. Consequently, whilst the Trust is working with
the system looking at both Commissioner and Provider QiPPs, this one year activity and operating plan
assumes negligible delivery of Commissioner QiPPs given historical trends.
The Trust recognises that, as submitted, this one year Operational Plan does not address the financial
sustainability of the sector. This will need to be done through the Five Year Sustainability and
Transformation Plans as part of the Accountable Care System and the wider Berkshire/ Oxfordshire/
Buckinghamshire footprint.
19
5 Workforce Planning
Trust workforce planning processes
The Trust is committed to a robust workforce planning process and workforce issues receive Board
attention which includes reporting on key measures to the Board as part of the Integrated Performance
Report. Regular progress reviews will also be undertaken by Senior Management Team and key risks
relating to the workforce are currently highlighted on the Board Assurance Framework and reviewed
monthly to ensure mitigating actions are in place. Where appropriate some developments such as 7 Day
working will receive support from the Trust’s PMO team to facilitate successful delivery. This will ensure
that these important developments receive appropriate support and scrutiny. The Trust workforce plan
will be submitted to Health Education Thames Valley for onward submission to Health Education
England. The Trust complies with the HEE requirements for plans to provide details by occupational
codes which specify the specialty and skill level of the future workforce.
The Trust regularly reviews all relevant metrics to identify workforce risk areas and produces a ward KPI
report that combines safety metrics with workforce indicators such as turnover and sickness absence,
which is reviewed by the senior nursing team. The workforce plan will be reviewed on a quarterly basis
to update the current workforce against the plan and to identify any actions required. Workforce risk
areas will be identified along with mitigation plans. Progress against mitigation plans will be monitored
by the Trust Workforce and Education Board.
System-wide development
The Trust is currently developing a workforce plan for 2016/17 which will be linked to the Clinical
Services Strategy. The plans are based on a template that incorporates the planned activity for each
service, the budgeted establishment, and a plan for temporary staffing expenditure through the year.
PESTLE and SWOT analyses identify the main influences on the service and the workforce strengths and
risks. Our clinical services teams have been developing and updating their strategies as part of an on-
going planning process. Workforce analysis was carried out across all services in June 2015. During the
latter part of 2015/16, services have been asked to consider the potential opportunities of a system-
wide Accountable Care System to deliver better value healthcare for our local population. Current
workforce KPIs are discussed together with reviews of new ways of working in order to achieve the
service QIPPs. The workforce planning documents are being used to identify workforce initiatives for
2016/17, but also to look ahead to further service redesign.
However, this work has particularly identified the need to review end to end pathways in detail with our
partners across the health and care system to ensure that the Trust is using scarce resources in the most
effective way. These discussions have sought to identify how the Trust can better use people to provide
services and what opportunity there would be to do things differently. This detailed planning will then
be used to develop transformational workforce plans for the Trust and other providers in the pathway
which ensure the achievement of a sustainable balance between high quality safe services and
affordability.
20
The work that will underpin the Trust workforce plans will be conducted in parallel with the Berkshire
West 10 Workforce Integration & Workforce Planning Project, with which the Trust participates. This
Project plans to include the redesign of the workforce across the system linking to the Better Care Fund
national conditions including 7 day working across health and social care, care co-ordination, joint
assessments and care planning. The BCF schemes that include workforce redesign include: Hospital at
Home; Enhanced Care Home Support; Re-ablement Services Integration; Frail Elderly Pathway; Primary
Care Development.
Productivity and improvement
There is a continued focus on workforce productivity schemes including the reliance on (and cost of) a
temporary workforce and external agency workers. E-rostering software is used to ensure that staff are
allocated to shifts in the most efficient manner. The system prompts ward/service managers to reassign
staff where the shift is beyond the levels identified by the Director of Nursing as the appropriate staffing
level. There is a daily staffing huddle supported by robust, real-time roster reports, to review staffing
levels across the organisation and reallocate based on risk assessment. The Trust regularly reviews all
relevant metrics e.g. safe staffing levels and skill mix to identify any workforce risk areas and enable
rapid development of mitigating action plans. Nursing leads receive monthly rostering KPI reports that
highlight outcome against target including the use of agency staff against budget.
The Trust has a Workforce Productivity Delivery Programme which forms part of the CIP Service
Improvement and Transformation Programme for 2016/17. The savings target for this programme is
currently being developed, and for nursing CIPs will be reviewed in conjunction with the Safe Staffing
Review completed by the Director of Nursing. The Trust workforce plan will also reflect other significant
local transformation programmes e.g. the pathology services are being reconfigured to become part of
Berkshire Surrey Pathology Services; and the implications on local midwifery services of the National
Maternity Review and its recommendations for multi-agency involvement in the provision of pre and
post-natal care. The Trust will be implementing two workforce productivity schemes: one relating to
medical workforce productivity; and the other relating to the remaining workforce. The implementation
of an electronic job planning module will allow each service to better align the senior medical workforce
activity to the commissioned activity.
As a result of our planning work the Trust believes that there will be other system-wide transformational
workforce programmes that could deliver more sustainable service delivery. In maternity services there
is a significant shortage of qualified midwives. The Trust is investigating the potential to map key
interactions along the patient pathway through pregnancy, birth and early parenthood which may
identify tasks currently undertaken by midwives that could be done by others or could be provided in
more innovative ways.
Staffing levels
The requirement to use agency staff should be a balancing item to better match resources and demand
in a flexible manner. Therefore, a key focus remains on recruiting staff, reducing staff turnover and
21
reducing absence. The Trust performs well on sickness management in comparison with other NHS
Trust’s and has a 2.8% target rate which it remains in line with. Leave on wards is actively managed to
reduce peaks in annual leave that could lead to an increase in demand for agency staff. The new on-line
leave booking system for senior medical staff will improve the visibility of days booked and allow for
improved forward planning. Limits have been set on the number of senior medical staff within a
specialty who may be absent at any one time. This limit is set by sub-specialty within some surgical
teams with the aim of achieving improved theatre utilisation. Recruitment and retention meetings have
been set up with high agency use areas to identify reasons for vacancies and to discuss ideas as to help
to retain staff and develop initiatives for recruitment.
The Trust is currently reporting on a weekly basis any breaches against the agency rules (both the use of
non-framework agency and against the price caps). The Trust has an e-Rostering policy that details a
Standard Operating Procedure (SOP) for ensuring the most cost effective method of ward cover at safe
staffing levels as set by the Director of Nursing. This SOP is reviewed regularly by Care Group Directors
of Nursing to ensure that it is updated with current costing information and follows best practice. The
Trust is looking to review the roster production processes, so that details of the shifts which need to be
filled by temporary staff are made available more quickly. The Trust restricts non framework agency
usage and this is only considered to ensure patient safety. Every agency has been contacted to discuss
compliance with Monitor rates. Agencies that do not comply are removed from our tier 1 workflow and
placed on tier 2, whereby they receive the shifts 72 hours in advance, when a tier 1 agency are unable to
supply. Routine contracting is with agencies that are on the approved framework, although in
exceptional circumstances the Trust may have to go outside of the framework. New agencies are being
engaged that meet the agency rules. Senior Trust staff meet with NHS Professionals on a weekly basis
and scrutinise all breaches, both in regards to the price cap and the use of non-framework agencies.
The Trust is reviewing its bank rate against rates paid by surrounding trusts. The Trust has approved a
proposed rate increase for NHS Professionals Bank Staff in ICU in order to reduce the reliance on agency
staff. This will assist with our ability to achieve safe staffing levels whilst reducing cost and the number
beaches against the agency rules. The Trust is exploring the option of the proposed rate increase for
NHS Professionals Bank Staff in Paediatrics. The Director of Nursing or Chief Operating Officer is
required to authorise the use of Thornbury staff. In order to reduce agency spend the Trust is working
on a number of other initiatives including promoting the ‘refer a friend’ scheme, holding a number of
recruitment open days and proactively promoting joining our bank through the “Love the NHS”
campaign.
The agency spend ceiling for 2016/17 is set at £10.32m which is considerably below the expenditure in
2015/16. When the price caps were introduced the Trust met with the agencies to discuss how they
were going to continue their level of supply given the reduction in rates. All providers adhered to the
November price cap but when the February price caps were introduced some agencies were not
complying and as a result the tiering structure was implemented. The Trust operates a padlock system
so shifts are only released to approved agencies once the Trust bank has been exhausted. The Trust is
implementing tighter control measures to prevent unnecessary use of agencies. The Trust predicts that
whilst it will be a challenge to achieve, it will be able to manage within its agency ceiling for 2016/17,
22
but will continue to complete the self-assessment tool to identify opportunities to further strengthen
controls.
Safe staffing is assured by 6 monthly nursing skill mix reviews combined with robust daily planning and
risk management processes. The safe staffing reports are reported to the Board quarterly and actions
are identified to ensure that safety is maintained.
23
6 Financial Planning
Overview
The Board has approved this plan which assumes £9.9m incremental funding for 2016/17 from the
Sustainability and Transformation Fund, and accordingly delivers a planned financial surplus of £4.8m,
versus a £9.1m deficit in 2015/16. The Trust had £11.5m cash at the end of March 2016, and expects
£9.05m cash at the end of March 2017. The Trust expects to conclude 2015/16 with a FSRR of 2 and
expects this to remain at 2 through 2016/17.
The table below summarises the key financial KPIs by quarter.
£m Qtr1 Qtr2 Qtr3 Qtr4 Full Yr
FSRR 2 2 2 2 2
Trust Surplus/(Deficit) (£'m) (1.47) 1.25 2.70 2.33 4.80
Income (£'m) 98.27 99.92 100.19 98.69 397.07
Pay Costs (£'m) (55.19) (55.49) (55.62) (55.31) (221.62)
Headcount at quarter end 5054 5098 5132 5139 5100
Trust QiPPs (£'m) 3.72 3.89 4.10 4.99 16.70
Contingency (£'m) 0.00 (0.30) (0.60) (0.60) (1.50)
Restructuring (£'m) (0.75) (0.75) (0.75) (0.75) (3.00)
Capital Spend (£'m) (2.32) (5.92) (6.42) (5.34) (20.00)
Sale of Craven Road 0.00 1.30 0.00 0.00 1.30
Cash at quarter end (£'m) 10.50 10.11 15.67 9.05 9.05
Key Assumptions inherent in the 2016/17 operating plan are detailed below:
£m
Margin
Impact £'m)
Base Activity growth of circa 2% 6.13
Impact of CCG QiPPs 0.00
Tariff Inflator 1.9% 5.83
Sustainability fund 9.90
Pay cost inflation & Employer Pension Contributions (9.31)
Drugs Income growth at 4.5%, cost growth at 4.5% (0.23)
Non Pay cost inflation at 1.2% (1.21)
Increase in NHSLA costs (2.11)
Trusts QiPPs 16.70
Contingency (1.50)
Restructuring (3.00)
24
Income
Income is based on the roll-over of the ETO contract option as currently expected. This is consistent with
early contract conversations with Commissioners. However, those conversations are continuing and the
current Operating Plan as submitted is contingent on those negotiations concluding as currently
anticipated.
Whilst the Trust has included what might be seen as a conservative position with regards to growth we
are assuming that the 2016/17 contract will include a roll-over of winter funding monies received this
year (£1.2m) and that Commissioners will re-invest the MRET and readmission monies in-line with
current year (circa £3.5m). At this stage we have not included any activity reductions relating to
Commissioner QIPPs as history tells us that, notwithstanding the success of such schemes, the net
growth in activity has always been at least 2% for the Trust. This level of assumed growth in base level of
activity has traditionally been agreed with Commissioners as part of the planning assumptions and the
Trust expects that to be the same this year. The assumed activity growth provides income growth of
£6.2m, with a margin of £1.4m. The tariff inflator (1.9%) increases income by £5.8 whilst the allocation
from the Sustainability Fund increases income by £9.9m.
Pay
Pay includes a 4.3% inflation increase to cover an assumed annual pay award along with changes to
employer pension and NI contributions. Collectively these add £9.3m to the pay cost of the Trust. In
addition we have included an increase of £4.0m in pay to support the delivery of the incremental activity
growth. Reducing the pay costs is an assumed saving in QIPPs of circa £10.9m, with an assumed cost of
restructuring of £1.5m. Further detail on in year cost QIPPs is provided below.
We note that Monitor’s latest planning guidance suggests pay inflation of 3.3% which, if proved correct,
presents an opportunity versus the current budgeted pay costs of circa £2m.
Drugs Cost
Drugs cost has been assumed to increase at a rate of 4.5%, increasing costs by £0.255m.This is lower
than historical experience so has been included in our risk analysis. A further increase in drugs cost of
£2.92m in Planned Care is associated with correlated increase in drugs income.
Non Pay
Non pay inflation has been assumed at 1.2%, equating to £1.2m increased costs. NHSLA costs are
planned to increase by £2.1m as per our latest quoted contribution for 2016/17. Whilst we have
included these costs in our Operating Plan we have asked for further detail as it is not immediately clear
to us what is driving this increase in premiums and hence whether or not it is legitimate. Included in
non-pay in 2016/17 is an assumed restructuring cost of £1.5m. We note that Monitor’s latest planning
guidance suggests non-pay inflation of 1.7% which, if proved correct, presents a risk versus the current
budgeted non-pay costs of circa £0.5m.
25
Contingency
The Trust has taken a top level view of key risks and opportunities as a result of which we have included
a contingency of £1.5m, in line with the previous year. The table below summarises the main risks and
opportunities.
Residual Risks and Opportunities
Gross Assessed Surplus
Per Operating Plan 4.8
Risks:
Commissioner QiPPs deliver or reduced
NEL marginal rate reinvestment (6.00) (2.00) (2.00)
Trust QiPPs deliver at 75% (4.18) (1.00) (1.00)
Non Pay inflation at 1.7% (0.50) (0.50) (0.50)
Planned Care contribution risk (2.00) (1.00) (1.00)
Network Care contribution risk (1.00) (0.50) (0.50)
Opportunities:
Activity/tariff growth higher 2.00 1.00 1.00
Urgent Care contribution growth opp 1.00 0.50 0.50
Pay inflation at 3.3% 2.00 1.00 1.00
Restructuring costs restricted to £2m 1.00 1.00 1.00
Cost Contingency 1.50 1.50 1.50
Plan net of risks and opportunities (6.18) 0.00 4.80
Cash Management
The Operating Plan for 2015/16 resulted in the Trust being in a low cash position by December 2015.
Consequently the Trust signed a £10m working capital facility with the ITFF in August 2015. The Trust
does not expect to draw down any of this facility in 2016/17. Whilst the Sustainability Fund allocation
provides significant cash during the year it is noted that this is provided quarterly in arrears. The Trust
will continue to monitor the cash position weekly and will advise the Board on future risks that may
result in the need to draw down on the working capital facility.
Efficiency savings for 2016/17
Cost QIPPs
The Trust sought to introduce a more transformational approach to cost QIPP planning and delivery in
2015/16. Whilst this has had some success, progress has not been as much as hoped, so this approach
will be reinforced in our 2016/17 plan. From 2016/17 the objective is to align the QIPP Programme to
the Trust Road Map, ensuring that each year the QIPP programmes support the strategic objectives and
transformational change. Therefore in 2016/17, the Transformation portfolio focuses on ‘strengthening
26
our foundation’, through programmes aimed at increasing the efficiency of our resources to provide the
current services, building a solid foundation for future change
The Trust has identified some 18 programmes which are a combination of cost improvement, service
improvement and transformation schemes. Each programme has a senior management lead, a
programme lead and a named PMO support lead. All programmes have scoping briefs and Project
Initiation Documents. The scoping briefs detail the phasing of the savings, the key milestones and
baselines to monitor delivery and are signed off at the Trust Improvement Board.
These programmes can be categorised as cost improvement, service improvement and enabling projects
and include on-going programmes such as medical productivity, workforce productivity, theatre
efficiency, medicines management, patient flow, and business as usual, but have been supported by
new programmes which act as key enablers and identifiers of opportunities for transformation. Key
amongst these are technology transformation, and service line management
The delivery of the cost QIPPs are overseen by the Chief Operating Officer, working with the Director of
Finance. All programmes are monitored for delivery through the monthly Trust Improvement Board and
achievement is tracked through the PMO database. The executive team is briefed weekly on the cost
QIPP programme and the Finance and Resources Committee and Board receive monthly reports on
progress, and exception reporting where appropriate. There is a clear risk rating for each of the
programmes.
The Trust is targeting cost QIPPs of £16.7m in the Operational Plan. As at 13 April, the Trust had
identified actions with potential savings of £18.3m in 2016/17 (full year effect £21.3m), with a current
PMO risk assessment of £13.0m. Work continues to both improve the pipeline of opportunities and to
increase the PMO risk assessment. This is an area which has been modelled for sensitivities as part of
our risk and opportunities analysis. The Trust has allowed for restructuring costs of £3.0m within the
Operating Plan to deliver the cost QIPP Programme. The project which will incur the largest
restructuring costs is the consolidation of Pathology services with Surrey acute providers. Total
restructuring costs of up to £6m are expected, with £1.5m, being the share funded by the Royal
Berkshire. The Business Case shows savings in excess of £1.6m per year for the Trust with a payback of
circa 2.5 years when £2.6m capital costs of implementation are included. The cost of restructuring will
be monitored monthly to ensure that the Trust remains within budget or any further restructuring costs
are more than covered by incremental in-year savings.
The Trust has engaged positively with the Lord Carter team, particularly with regards to the model
hospital work done in autumn 2015, however, as yet we have not seen this translate into savings. The
Trust will accelerate our engagement with Lord Carter’s team and included his recommendations into
the relevant QIPP programmes. The commitment to the Lord Carter programme is underpinned by the
Board as part of our acceptance of the conditions of the incremental monies from the Sustainability
Fund.
The Trust is involved in the CCG QIPP programme although our financial baseline is not predicated on
the success of their programme. The Trust will continue to engage with the CCG to ensure that the QIPP
27
Schemes identify are realistic and implementable. The Trust will continue to work with the CCG to
identify opportunities for working together, if appropriate, as part of their QIPP agenda. Once agreed we
will also need to ensure the Trust’s QIPP programme is linked to ACS priorities and the Sustainability and
Transformation Plans.
Agency Rules
The Trust reviews its agency spend on a monthly basis at its Board Finance and Resources Committee
Meeting. Whilst there has been some reduction in agency spend, particularly within administration and
management there are a number of areas where the availability of staff remains challenging, vacancy
rates remain high, and hence our ability to reduce agency spend has proved difficult. These are nursing,
operations management and IM&T. The Trust has a number of on-going actions to continue to seek to
drive a reduction in agency spend as outlined below.
Procurement
Procurement has helped the Trust to deliver significant cost savings over a number of years achieving
£2.9m in 2014/15 and forecasting savings of £2.8m in 2015/16. In order to tighten procurement controls
on capital works an Internal Audit report was commissioned which made a number of recommendations
in light of which the Trust has introduced an electronic tendering system. The Trust shares its data on
prices paid for non-pay items. Clinicians are engaged appropriately in trialling some items ahead of
making purchasing decisions.
A key development in the management of non-pay in 16/17 will be the implementation of an electronic
inventory management system which will see significant benefits through improved ordering and
stockholding. The Trust will also continue to engage positively with Lord Carter’s team to drive the
maximum benefits of broader sector wide benchmarking of usage and bulk pricing.
Capital
The Trust is in the middle of its capital planning for 2016/17 with the potential calls on the capital
programme far exceeding what is likely to be affordable. Whilst calls on the capital programme
currently total circa £40m, only £30m can be afforded with £17.5m being funded directly by the Trust,
£10.0m being funded by lease or new financial arrangements such as loan or managed services, and
£2.5m being funded by charity. The table below shows an indicative split of the capital programme at
this stage.
28
£m
Buildings- Statutory 3.92
Buildings- Maintenance 2.75
Buildings- Major Works 15.23
Medical Equipment-below £100k 4.30
Medical Equipment- over £100k 8.00
IM&T 6.18
Prioiritisation need to limit capex (10.38)
Total Trust Spend 30.00
Lease / other funding (10.00)
Charity / third party grants (2.50)
Total Trust Cash Funding 17.50
The above programme is based predominantly on those areas of spend that the Trust regards as
essential, such as buildings works, which is required to maintain the state of assets such as medical
equipment replacement and IM&R sustainability work, or which directly contributes to in year savings as
part of the Trust’s cost QIPP targets. Work continues on reviewing and prioritising capital spend, along
with sources of funding.
The Trust has an active programme of disposals with proceeds from disposals totalling £2.0m in 2015/16
and proceeds in future years expected to exceed £1.1m. The Trust is working with the local Health
Sector, Local Authorities and Lord Carter’s team on a strategic approach to estates management within
our area as a means of identifying further efficiencies where possible.
Financial Sustainability
The Trust recognises that, as submitted, this one year Operational Plan does not, of itself, address the
financial sustainability of the sector. This will need to be done through the Five Year Sustainability and
Transformation Plans as part of the Accountable Care System and/or the wider
Berkshire/Oxfordshire/Buckinghamshire footprint