1 year operational plan submission to monitor

First choice for orthopaedic care

Monitor Visit 02 June 2015

ENC 9a


Agenda Item Points for Discussion

Welcome & Introduction

1. General Overview of Plan • Main features of the plan (short term resilience) • Key Risks • Longer Term Strategy

2. Finance • Contracting • Assumptions • Financial Sustainability • CIPs • CQUINs • CAPEX

3. Quality • Operational target risks • Capacity • Workforce

4. AOB • Medicines Management

Monitor Visit Agenda


1. General Overview of Plan


Key Strategic Objectives in the Operational Plan

Delivering today and transforming for tomorrow towards these strategic goals: • Delivering exceptional patient experience and world class outcomes • Developing services to meet changing needs, through partnership

where appropriate • At the cutting edge of knowledge, education, research and innovation • With safe, efficient processes that are patient centred • Delivered by highly motivated, skilled and inspiring colleagues


A year of Change, transformation & investment

• 3% growth • MSK Health & Well-being • Working with Partners • Monitor Project / New Models of Care • Outpatient Redesign • Investment in transformation programme • Workforce Transformation • Continuing to strengthen our governance approaches • Organisational redesign • Integrating our education, research and innovation

activity


Our Headline Service Strategies

MSK well-being,

preventative, diagnostic

and Advice & Guidance services

Routine elective

growth c2%, elective

efficiency requirements

& demographics

Specialist orthopaedic,

spinal and oncology growth &

concentration in centres

Opportunities for expansion into MSK well-being services, diagnostics, prevention and non-surgical services. Engage differently with GPs.

CCGs reductions but increases in demographic need and choice. Non-spec. niche. SLAs for ROCS. New models of care Centre of Network

National specialised services review. Expect more centralisation and specialist centres. Long waits and growth evident. Tariff challenges

New

Unknown potential -international offering, private patient services to compensate CCG demand management and amenity services.

(8.6%) (56.3%) (33.7%) (1.4%)

6


Strategic Transformation & Operational Plan Progress Against Delivery Of The Strategy

7 Transformation work streams aligned to the strategy, enabling operational delivery of change have been created. Highlighted progress from across the programme includes:

Capabilities and Culture • Staff engagement events – “New Beginnings” • Embedding of our values and behaviour framework • Kings Fund diagnostic on barriers and enablers to medical leadership Board Capabilities • NED’s - strengthen clinical governance & clinical improvement knowledge • Appointments to key vacancies on the Executive Team • Board development sessions


Strategic Transformation & Operational Plan Progress Against Delivery Of The Strategy

Culture • Empower all staff to deliver transformation in their own areas of work • New focus on patient safety • Revised and updated Board Assurance Framework (BAF) • Root and branch review of governance systems Processes and Structure • The Trust Board has overseen a programme of detailed actions to improve

critical processes related to quality governance. • Terms of Reference of all Board Committees have been reviewed • Ongoing CGC review of all groups reporting to Clinical Governance Committee • Directorate restructure


Transformation Programme - Delivery workstreams Work Stream Overview

Work Stream 1. Creating a Culture of Excellence, Innovation and Service

Executive Lead: Director of Workforce and Organisational Development

• Restructure

• Change Leadership Capability

• Leadership Strategy

• Board Development

• Values

• Awareness

• Appraisal

• Recruitment

• Clinical Standards

• Learning Strategy

Work Stream 2. Exceptional patient experience at every step of the way

Executive Lead: Director of Operations

• Outpatients

• Theatres

• Patient Journey

• Referral Management

• Pre-Operative Assessment Centre

• List Planning

• ADCU

• Discharge Planning

• Post Discharge

• Patient Flow

• Patient Communication


Work Stream 3. Safe and efficient care

Executive Leads: Medical Director and Director of Nursing and Governance

• Digital Dictation

• Enhanced Recovery

• Electronic Document Transfer ( EDT )

• 7 Day Working / Service

• Medical Workforce Review

• Electronic Prescribing and Medicines Administration (ePMA)

• Organisational Governance

• Nursing Acuity Tool

• Point of Care Testing (POCT)

Work Stream 4. Fully engaged patients and staff

Lead: Head of Communications

• Communication and Engagement Strategy

• Team Development

• Systems and Process

• GP Engagement - ROH First Choice

Transformation Programme – Delivery workstreams Work Stream Overview


Work Stream 5. Clinical Services Development

Executive Lead: Director of Operations

• West Heath Hospital Project

• Develop Orthopaedic Network

• Private Patient Strategy

• Direct Access Ultra-sound

• Collaborative Service Delivery (e.g. Walsall)

• MSK – Well-being, Advice, Diagnostics (GP’s)

• Estates Strategy Review and Update

Work Stream 6. Information for Excellence

Executive Lead: Director of Finance

• PAS Upgrade

• ORMIS Replacement ( Theatre System)

• PAS Replacement

• Virtual Desktop Infrastructure (VDI)

• Outcomes (Amplitude)

• Theatre Screen Replacement

• NHS SMS Product Replacement

• IT Infrastructure

• Managed Print Services

• Business Intelligence

Transformation Programme – Delivery workstreams Work Stream Overview

Work Stream 7. ROH: the knowledge leader

Executive Lead: Medical Director

• Research + Innovation

• Academic Strategy

• New Models of Care


Short-term Delivery Risks

• Delivering today, whilst transforming for sustainable service quality

• Tariff anomalies – especially complex specialist work (spinal, revisions)

• Contractual penalties – esp. national capacity issues (e.g. spinal deformity)

• Reducing 52 week waits

• Maintaining delivery of RTT

• Interim workforce solutions (locum & agency) pending strategic solutions

• Clinical Engagement & Clinical Leadership

• Development of new Board, Executive Team & new operational structure

• Further development of our governance approaches

• Health system planning


2. Finance


Challenges and Risks

2014/15 proved a difficult financial year - key cost pressures resulting in a deficit of £432,000

• Increased reliance on locum and agency staffing from £2.8m in 2013/14 to £4.7m in 2014/15 ( Medical Workforce Review project will seek to reduce this reliance)

• 63% of 2014/15 costs were incurred in the last 6 months of the year

Causes

• Challenges in recruiting to junior doctor and theatre practitioner posts

• Changes in ward rotas to comply with safe staffing levels

• Vacancy costs in some senior and middle management posts

Modelling into 2015/16 the full year effect of these costs, alongside a number of non-recurrent items in the 2014/15 position, results in the Trust starting the new financial year with a recurrent baseline deficit of £1.2m on a like-for-like basis


Tariff reductions in addition to efficiencies add further pressure in 2015/16

There remain a number of uncertainties in this planning:-

• Future plans for funding based upon a reasonable resolution with regards to some of the anomalies within the orthopaedics tariff

• Delivery of sustainable staffing solutions in our key clinical areas and the efficiency opportunities resulting from our transformation agenda being delivered

The Trust anticipates being able to reach a breakeven financial position by 2017/18. The cash impact of the deficit position in 2015/16 and 2016/17 has been reviewed, and appropriate alterations to the Trust’s capital programme have been made to ensure that cash is maintained at a level in line with the original five year financial plan

Challenges and Risks


Headlines & Financial Sustainability

• Planned deficit of £2m for 2015/16

• Plan to return to breakeven by 2017/18

• Continuity of Services rating of 3 for 2015/16


Contracting

• Contracts agreed and signed with CCGs. NHS England contract not yet signed, but anticipated this will take place in next week. No major concerns.

• Growth of 3% included within CCG contracts


Assumptions

• In line with Monitor guidelines, however increased financial pressure driven by £1.5m loss of tariff before the impact of the tariff deflator


CIPs

• CIP target of £2.8m (3.55)

• £2.3m of expenditure schemes, plus £0.5m of income schemes

• Main expenditure schemes:

– Reduced LOS (West Heath repatriation) - £375,000

– Prosthesis savings - £300,000

– Digital Dictation (Removing agency and outsourcing) - £200,000

– Reduced locum spend (mainly POAC) - £150,000

• Various efficiency schemes, building on Newton work (Cancellations, List Utilisation, DNAs etc.) - £615,000


CQUINs

• All agreed, with delivery plans being monitored through the transformation team and programme management process


CAPEX

• Planned Capital Spend of £8.1m in 15/16

• Funded from £2.8m of depreciation and £5.3m of cash reserves and creditor movements

• Main schemes (ePMA - £2m, Radiology Equipment - £1.2m, Theatre feasibility and foundations £1.2m, Theatre improvements £0.5m)


3. Quality


Operational Target Risks

• Q1 concerns for non-admitted target – stability will be returned Q2

• 62 day cancer tertiary referrals will continue to challenge, recognising local commissioner expectations

• As relationship with Walsall Healthcare grows and new referrals are forthcoming, attention will be focused on maintaining target clarity

• There will be an enhanced risk to delivery during the introduction of the revised operating structure

• 52 week waits for spinal and spinal deformity

• Consultant recruitment risk with ortho-oncology, spinal and young adult


Capacity

• Outpatient 6 week milestone both during restructuring of outpatient flow and mirroring the pace of market share growth

• Fast track stream to pre-operative assessment currently resulting in missed table opportunities

• Mainstreaming enhanced recovery/ early supported discharge

• Increasing operative restrictions being introduced by Birmingham Children’s Hospital

• Consultant productivity modelling

• Strategic estates considerations

• Ability to influence Birmingham Children’s Hospital and its continued under-provision of SLA contracted theatre sessions


Workforce

1. Workforce Numbers/Capacity

• Planned areas of growth – physicians associates (part of the solution to a sustainable workforce model & as a result, reduce agency spend on locum doctors in POAC by year end) , MSK service (ESP and sports physician – service growth), Nursing ( 10 – 15 WTE conversion of bank/agency to permanent roles expected by year end) .

• Potential for redundancy of 1 - 2 individuals linked to corporate restructuring and ending of external funding ( research monies)

• Sickness absence remains cause for concern as higher than specialist trusts. Focus will be on holding managers to account for their performance and implementation of well-being initiatives.


Workforce (2)

2. Culture and Capability

• Staff Engagement – new beginnings events ; staff involved in pathway re-design & actions to build confidence to raise concerns. Feedback from events to be presented at EMT in August

• Leadership Development – report from Kings Fund awaited – will be used to design clinical roles and the development interventions for new appointees. Leading change is a key priority area.

• Creating a culture of improvement – key first step is building staff confidence in raising concerns (key improvement area from staff survey). Intention is to adopt ‘Raising Concerns’ campaign as successor to ‘speak out safely’ - include management development and internal communications of learning from incidents


Workforce (3)

2. Culture and Capability

• Organisational Structure – appointments made to operational roles and structure on plan to be live from 1 August. Focus needed on preparation to ensure success and appointment to AMD roles to lead Divisions.

• Values – roll-out of embedding into recruitment, appraisal and reward. How to tackle inappropriate behaviour is a key part of the ‘new beginnings’ sessions.


Workforce (4)

3. Key Operational Risks

• Theatre staffing – residual vacancy position is circa 9 WTE for band 5 practitioners plus predicted retirements during 2016. Engaged an overseas partner Medi-placements and will recruit from Philippines for new starters in Q4. Agency reduction likely to be realised at end Q1 2016/17.

• Retirement of sub-specialty consultants – opportunity to bring in modernised thinking but threat to continuity. Advanced planning for replacements and potential international search will reduce likelihood of risk materialising in practice.

• New medical workforce model – design of all new model, changes to rotas for junior doctors and recruitment of physicians associates. Purpose is to improve care for patients and reduce expenditure. Expect implementation in POAC in year, but in other areas in 2016/17


GGI Action Plan

Progress against our Good Governance Institute Action Plan continues, and we are on target with delivery having recently delivered on the following actions:

• Recalibration of the BAF – including incorporation of strategic risks etc.

• Annual Board cycle approved at April Board

• TOR of all Committees reviewed and revised structure diagrams completed for discussion

• EMT status clarified

• Recruitment of substantives on target

• Policy on Policies approved (revise again in October)


CQC

• Monthly Board updates on actions from the previous inspection – Embedded delivery plans

• Return CQC Visit 28 & 29 July 2015 – focus HDU & OPD

• Assurance visits recently strengthened – including NEDs and Governors and aligned to KLOE

• Education of our staff with KPMG

• Working beyond boundaries: – Stanmore Peer Review of Nurse Staffing

– Active in Critical Care Network and peer reviewed by them

– Paediatrics HDU Nurses now have honorary contracts with BCH


4. Any Other Business

- Medicines Management


Medicines Management

• Response to Coroner

• Reviewed and revised our Controlled Drugs audits and SOPs

• Revised the Terms of Reference for the Medicines Safety Group (extending the membership)

• Revised the Terms of Reference for the Drugs and Therapeutics Committee – making Controlled Drugs a standing item on the agenda

– Revised the frequency of reporting to the CGC and the Board from quarterly to bi-monthly

• Our routine checks are now showing compliance


Questions?

1 year operational plan submission to monitor

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