Integrated business plan
2014/15 – 2018/19
June 2014
Executive summary
This executive summary provides a short summary of the key elements of this integrated business plan (IBP). It provides a high-level overview of the East and North Hertfordshire NHS Trust (ENHT), our vision, the market in which we operate and our performance. It also explains why we are applying for NHS foundation trust (FT) status and how becoming a FT will help to deliver our vision.
The trust
ENHT is at a seminal point in our history. The trust, which provides a wide range of local and regional secondary care services to people living in Hertfordshire and beyond, will by the end of 2014, have delivered one of the most complex recent service reconfigurations in the NHS. As a result of theOur Changing Hospitals(OCH) programme we will have invested £150m to transform emergency and inpatient care for local people. OCH is about positioning the trust so we can:
• Improve clinical outcomes • Develop specialist services • Improve the patient environment • Achieve economies of scale • Recruit the best staff.
Post-completion of OCH we will have centralised emergency and inpatient services at the Lister Hospital, Stevenage and worked with commissioners to transform the Queen Elizabeth II Hospital in Welwyn Garden City to become a mainly ambulatory care local hospital providing services such as outpatient clinics, diagnostics and urgent care. Through delivery of OCH the trust will be in an excellent position to tackle the challenges of the next five years.
Following OCH we will be a trust serving a local catchment population of 600,000, employing circa 4,700 w.t.e. staff and with a turnover of approximately £340m. This scale, supported by clinical networks and local satellite delivery centres, is sufficient for us to meet Royal College and NICE guidance on providing a wide range of sub-regional specialist as well as local health services.
During 2013/14 we acquired the Surgicentre, an elective surgical centre on the Lister Hospital site that had formerly been operated by an independent sector provider. The facility was safely transferred to the trust following concerns about quality under its previous management. We renamed the centre, the Lister Treatment Centre.
We aim to be amongst the best acute trusts in the country, an aim we are already making progress towards by driving down mortality rates, incidents such as falls and pressure ulcers. Our improvements are evidenced in improving patient feedback e.g. the Friends and Family Test results and in our winning a number of national awards.
Success story – national recognition
• The trust’s urology service has become the first in the country to be recognised by the Royal College of Surgeons as a national centre for robotic urology surgery training.
• In March 2014 the Lister’s neonatal unit received the ‘Outstanding Neonatal Team of The Year’ from Mother and Baby magazine.
• We have won national awards for our band 1 – 4 apprentice programme and our work with the Prince’s Trust.
The market
We operate in two markets. Our local health care economy consists of East and North Hertfordshire and surrounding areas; the market for our specialist cancer services provided from the Mount Vernon Cancer Centre (MVCC) is much larger – some two million people living across north west London, the east of the Thames Valley, Hertfordshire and Bedfordshire.
We have a healthy mix of commissioner customers. 61% of our income comes from the local clinical commissioning group (CCG), which importantly is a relatively stable health economy. Neighbouring health economies are less financially stable, but our exposure to each is relatively small with none exceeding 6% of our turnover. We also generate 28% of our income from specialist services predominantly cancer.
The two principle determinants of ill health are deprivation and age. Our local population can be characterised as being relatively ‘healthy and wealthy’ compared to national averages. Although there are pockets of deprivation the level of local health need reflects the area’s relative economic profile. The local population has an age profile close to national averages meaning our service mix is not skewed towards services for older people. Looking ahead we will face significant rising demand due to the twin effects of a growing population (expected to rise by 26% by 2035) and an ageing population (the number of people aged 65 and over is predicted to increase by 75% by 2035). Our greatest external challenge over the next five years will be the need to respond to financial pressures within the NHS without compromising quality and outcomes. The predicted national funding gap of £30bn a year by 2021 translates into the need for this trust to achieve efficiencies of between 4% and 5% per year over the period to 2018/19. A major theme in the local health economy’s response to this challenge is the introduction of better integrated services spanning acute, primary, community and mental health care as well as social services.
Another element of the national policy response is to encourage competition between providers whether through Any Qualified Provider (AQP), Patient Choice, and the use of competitive tenders for particular services or pathways. In common with most acute trusts we dominate the local market for what we do – see graph below.
Figure 1: Market share by commissioner
Unusually our market share is expected to increase rather than decrease despite choice because of the transfer of the treatment centre to the trust. Nevertheless we are not complacent and will compete for market share in neighbouring areas where this makes clinical and economic sense to do so e.g. through working with commissioners to look at opportunities in Bedfordshire. Our share of the Hertfordshire cancer market is close to 50% for both clinical and medical oncology i.e. the services provided at MVCC.
The events reported in Mid Staffordshire from 2008 onwards have led to a re-examination of quality and safety standards and governance within the NHS. Trusts such as ours are required to focus on basic standards of care and employing the right number and mix of staff needed to deliver that care. The medical Royal Colleges have set out a range of challenges for the future configuration of hospital services. In general, there is an impetus for larger units that can offer ‘critical mass’ in terms of service volumes, so that medical staff can retain and develop skills; and where it is easier to organise rotas and shifts to conform with employment law. Where centralisation compromises local access, organisation in networks, working across hospital boundaries is required. This suggests collaboration between providers, where a smaller provider may look to a larger neighbour to reinforce capacity and capability.
Having reviewed the market we have agreed a strategic response reflecting:
• The relatively affluent and growing population which contains some pockets of deprivation and associated poorer lifestyle and health
• The financial challenge facing commissioners and providers which reflects the growing elderly population, with associated growth in long term health conditions
• The need for service integration, particularly with community services, in response to these challenges
• The need for locally accessible services
• The need to further develop clinical networks to support our more specialist services
• Our potential to increase market share, particularly in Bedfordshire
Vision, values and strategy
The scale of our ambition is reflected in a very simple vision statement.
To be amongst the best
Using our new service configuration we will improve to the point that we are constantly delivering amongst the best clinical and service outcomes in the country. We recognise that to be amongst the best we also need to ensure we have the right culture and behaviours, so we have developed clearly defined values that set out how we will work as an organisation.
Figure 2: Our values
Our values mean that working as a team we will always put the patient’s needs first. Team not silo or individual working will be the norm to ensure that each patient benefits from our collective skills and resources. We will always strive to do our best in every situation and to continuously learn when things do go wrong. When mistakes occur or when we need to make difficult decisions we will do so openly and honestly.
We have engaged with stakeholders including commissioners, public health and the Health and Wellbeing Board to help answer the post-OCH ‘what next?’ question. This engagement resulted in us agreeing the following six strategic aims for 2014 - 2019.
Our six strategic aims
1. To continuously improve the quality of our services in order to
provide the best care and optimise health outcomes for each and
every individual accessing the trust’s services
2. To excel at customer service, achieving outstanding levels of
communication and patient, carer and GP satisfaction
3. To provide and support the best standards of integrated care for
the elderly and those with long term conditions by developing
key partnerships and services
4. To consolidate services and enhance local access to specialist
services in order to deliver high quality, safe, seamless,
innovative and integrated services which are sustainable
5. To support the provision of leading local and tertiary cancer
services and continued development of the Mount Vernon
Cancer Centre
6. To improve our staff engagement and organisational culture to
be amongst the best nationally
Our six strategic aims are supported by three strategic themes; ‘quality and experience’; ‘lean and productive’; and the development of clinical service strategies. Taken together our six aims and three themes provide the framework for what we must deliver over the next five years.
•
Continuous quality improvement is essential to enabling us to be recognised as one of the best trusts in the country. This aim reflects the expectations of our customers and is key to ensuring our organisation remains clinically, operationally and financially sustainable in the long-term•
We have listened to our customers and know that there are times when we let them down. Our goal of excelling at customer service talks to this recognition and embodies a series of changes that will result in the trust being ‘easy to use’ for patients, referrers and commissioners, as well as our staff.•
There is a clear drive internationally, nationally and locally towards better integrated or joined-up care especially for our older patients and their carers. Our aim is to provide services that are better integrated both within and without our hospitals so our customers can be assured that the continuation of their care will not be interrupted by transfers between services and that at each stage of the pathway those delivering care are fully aware of our customers’ wishes, needs and medical history.•
People want as much of their healthcare as possible delivered locally. Medical advances and innovations such as tele-medicine make this possible for an increasing array of the most specialist services. We know that nationally some services have been ‘over centralised’ creating problems for patients and carers who do not have easy access to transport. We aim to operate a model of care which delivers services ‘locally when possible and centrally when necessary’. We will do this by working with commissioners, GPs and clinical networks to develop and support local access to specialist services building on the model we have introduced for renal dialysis units.•
We have invested significant funds in developing MVCC services and now partner with the world renowned Royal Marsden NHS FT and the Institute of Cancer Research in an academic partnership. Over the next few years we will work with Hillingdon Hospital NHS Foundation Trust (the landlord of MVCC) to improve the infrastructure of the MVCC to that necessary for the continued delivery of first class cancer treatments.•
We are and will remain a ‘people business’ and we recognise that our most important asset always has been and always will be our people. We have made real progress in developing levels of staff engagement and organisational culture through our ARC programme, but we recognise that there is more to do. Achieving our vision to be amongst the best means we need to recruit and retain staff who are amongst the best available because staff engagement is key to patient and staff experience, safety and quality of care – put simply, motivated and engaged staff deliver better care for patients.Proposed service developments
In March 2014 we refreshed our SWOT analysis. Table 1: Strengths
Our strengths
Implications and plans
•
The completion of OCH will leave us with a clinically and financially sustainable organisation•
Creates a solid base from which to provide clinically and financially sustainable services and deliver changes needed over the next five years•
A stable management team with a track record of delivering complex and potentially contentious change•
Well established strategic relationships. Viewed as being ‘a safe pair of hands’ by the TDA, commissioners and local community•
Good local reputation – good links with local communities, CCG, media, councils, MPs etc•
Excellent position from which to understand and jointly develop solutions to shared strategic challenges whilst further improving our reputation•
A range of specialist services e.g. Mount Vernon Cancer Centre, plastics, ENT, renal and urological cancer. Developing new specialist services e.g. PPCI 24/7•
Sets out the trust as being ‘more than just a local DGH’ and creates opportunities to grow sub-regional services•
Growing reputation for research and education – AHSN node lead•
Provides research base to support pathway changes and growth of sub-regional services. Helps the trust attract high calibre staff•
Modern environments at the Lister and post-spring 2015 QEII•
Provides environment designed for delivery of 21st century healthcare and enables opportunities to redesign pathways, improving quality and efficiency•
•
Delivering local access to services – ambulatory care at QEII and Hertford, renal satellites, community paediatrics, Cheshunt minor injuries unit•
Demonstrates alignment to CCG strategy of delivering more care locally•
Established provision of some community health services e.g. community paediatrics•
Creates base from which we could grow our community-based service offer•
Lister Treatment Centre•
Opportunity to grow profitable elective market share Table 2: OpportunitiesOur opportunities
Implications and plans
• Opportunity to redesign patient pathways
• The delivery of OCH creates the opportunity to redesign patient pathways (both inpatient and outpatient) to be aligned to commissioning intentions whilst also delivering the efficiencies we will need over the next five years
• Commissioners’ integration strategy and Better Care Fund
• The Better Care Fund and commissioning intentions create an opportunity for the trust to expand along the care pathway and provide more community-based services centred on, but not wholly delivered from, the new QEII and Hertford General hospitals
• Build upon good community engagement generated through OCH
• Excellent foundation for FT membership and governance. Creates reservoir of community champions and focus groups to help us redesign pathways
• Opportunity to grow research activities via CRN and EAHSN
• Provides evidence base for redesigned pathways and creates potential to partner with local pharma/ medical industry. Helps to attract trainees and high calibre staff
• Opportunity to grow more specialist services e.g. robotic surgery, hyper-acute stroke, PPCI, ENT and plastics on the back of existing strength and national reviews
• Our emerging service development plans will include a response to identified opportunities
• Challenged nearby acute trusts • Creates opportunity to expand market share in Bedfordshire and south east Hertfordshire – capacity available in treatment centre
Table 3: Weaknesses
Weaknesses
Implications and response
• Trust administrative processes and systems can be difficult to use
• Risk to reputation particularly with patients and referrers: ultimately a risk to market share
• Potential lack of capacity to deal with scale and pace of change
• Risk to our ability to build upon opportunities created by OCH
• Focus on consolidation has limited focus/investment/attention on other strategic issues post 2014/15
• Risk the trust ‘pauses to take breath’ post-OCH and loses ground to competitors
• Management information - limited resource and expertise to produce management information and business intelligence e.g. market analysis and patient level financial data
• Risk to informed decision making
• MVCC geographical distance from trust, physical infrastructure and lack of control over site
• MVCC is a key service to the trust which risks a lack of focus. Our ambitions for the service can be constrained by a lack of support from landlord
• IT systems - lack of strategic direction, investment, capacity and infrastructure including patient records, decision support tools and wifi
• Inability to gain efficiencies and to seize service redesign opportunities enabled by/ dependent on IM&T
• Some legacy reputational issues around Clinicentre (Surgicentre)
• Risk to ambition to regain market share lost to competitors under Clinicentre’s previous management • Lack of clinical resilience in some
sub-specialties eg spinal orthopaedics and weak stroke services in context of HASU review.
• Risk to continued provision and destabilising impact on plans to grow specialist and sub-specialist work
• Lack of pathway-based
commissioning and over reliance on community provider
• Lack of control over pathways in and out of trust – risk to need to operate with fewer beds post-OCH
• Lack of strong clinical leadership in certain (sub)specialties/ mixed calibre across organisation – some areas lack strategic vision
Table 4: Threats
•
Threats
•
Implications and response
• Risk that completion of OCH in Oct ’14 is viewed internally as the end point rather than the starting point
• Risk the trust loses momentum due to change fatigue which could risk delivery of OCH-based benefits • Ability to address MVCC physical
infrastructure
• Deterioration in experience and ability to recruit/retain high calibre staff leading to reputational damage. Impact on financial surplus associated with MVCC
• Financial climate • Need for very significant efficiencies during life of this IBP (circa 25%) – risk of failure to redesign services to match income, reduced tariff – fixed costs.
• Variable management skills creates a risk we fail to deliver on the scale and pace of change needed
• Risk to delivery of our plans – to be mitigated through programme management process
• Rising customer expectations • Potential for loss of activity through choice if trust is perceived as being ‘difficult to use’
• Service specifications for specialist services and regional potential to reduce number of providers
• Our plans to expand more specialist work rely on our ability to deliver high quality, sustainable services in line with new national service specifications and our ability to influence commissioning decisions
• Inability to respond effectively to meet
significant/unmanaged/unanticipate d change in demand e.g. significant flows from Bedford/PAH. For example we have OPD capacity constraints/risk to RTT standards
• Failure to convert the opportunity to grow market share outside of our current catchment area
• Clinical sustainability: maintaining medical workforce - retention of consultants and specialties due to reduction in trainees. Linked to lack of resilience in vulnerable sub specialty services
• Risk to clinical viability to be mitigated by delivering our workforce engagement and cultural change plans
Our development plans reflect our assessment of the market assessment and our SWOT, and set out how we will achieve our vision and strategic aims. In turn the service developments drive changes to our finances and workforce, and will create new risks requiring mitigation.
At this point in our development we have two categories of service development:
•
Completion of OCH•
A range of emerging post-OCH developments.The final phase of OCH involves 11 projects, four of which have already been delivered. The remaining seven will be completed by the end of October 2014. As a result all emergency and inpatient services will be centralised at the Lister and the old QEII will close and a new £30m facility, the New QEII will open in its place. The New QEII will have a significant range of services - most
provided by this trust – including; a 24 hour urgent care centre; outpatients; GP services; diagnostics; a rapid Assessment Unit; endoscopy and day treatments; ante and post natal services; a dedicated Children’s Zone; therapy services; a breast unit; and an integrated pharmacy.
There are a number of risks linked to delivery of OCH:
•
Movements in the activity anticipated in OCH plans, for example greater than assumed growth in emergency demand.•
The risk that quality is adversely impacted whilst changes are being made.OCH is predicated on a number of variables, some within our control (e.g. performance measures, delivery of capital programme), and some which are largely in the control of others (e.g. commissioner’s delivery of intermediate care facilities and demand management plans). Our approach to managing these risks includes the following measures.
•
Active management and focus on those factors within our control•
Increasing our influence over as many of the variable factors as possible e.g. engagement with commissioners on the development of demand management plans•
Development of flexible contingency plans to create additional capacity if this becomes necessary.Theemerging developmentslinked to our strategic themes are:
•
Quality, including changes to promote 7 day working; ensure continued receipt of CQUIN monies; improve customer service and make the trust 'easy to use'; introduce integrated clinical pathways•
Lean and productive including development such as patient level costing and the IM&T strategy as well as our annual cost improvement programme•
Clinical strategy, a series of specific business case based service development such as; a hyper acute stroke unit; vascular, MVCC, a radiotherapy satellite at the Lister; and new theatres and paediatric unit.We will also develop a suite of enabling strategies to underpin and support delivery of the clinical strategy and associated service developments. Some of these strategies already exist and will need a refresh e.g. the estates strategy, whilst some need more fundamental work e.g. the IM&T strategy. Each will be delivered in parallel with detailed work on service developments.
Financial plans
Our financial plans are driven by nationally defined assumptions about tariff deflation and cost inflation plus the forecast changes to the trust’s activity as shown below.
Table 5: Activity forecasts 2015/16 to 2018/19
The resulting income and expenditure and resulting surplus forecasts are shown in the table below.
Admitted Patient Care (spells) 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 Elective
Basepoint 31,355 31,355 31,355 31,355 31,355 31,355
Population growth 0 845 1,218 1,595 1,976 2,361
ISTC Transfer 5,682 5,682 5,682 5,682 5,682
QIPP* (533) (533) (533) (533) (533)
Total per LTFM excl developments 31,355 37,349 37,722 38,099 38,480 38,865
Catchment 0 0 0 0 0 0
Total all changes 31,355 37,349 37,722 38,099 38,480 38,865
Emergency
Basepoint 40,778 40,778 40,778 40,778 40,778 40,778
Population growth 2,394 2,797 3,199 3,604 4,014
QIPP* (2,300) (2,300) (2,300) (2,300) (2,300)
Total per LTFM excl developments 40,778 40,872 41,275 41,677 42,083 42,493
Catchment (547) (1,094) (1,094) (1,094) (1,094)
Total all changes 40,778 40,325 40,181 40,583 40,989 41,399
Total Admitted Patient Care
Basepoint 72,133 72,133 72,133 72,133 72,133 72,133
Population growth 3,238 4,015 4,794 5,581 6,376
ISTC Transfer 5,682 5,682 5,682 5,682 5,682
QIPP* (2,833) (2,833) (2,833) (2,833) (2,833)
Total per LTFM excl developments 72,133 78,221 78,997 79,776 80,563 81,358 Catchment** (547) (1,094) (1,094) (1,094) (1,094)
Table 6: Statement of Comprehensive Income Projections 2015/16 to 2018/19
Delivering the level of surplus forecast is dependent upon delivery of CIP.
Mar - 14 Mar - 15 Mar - 16 Mar - 17 Mar - 18 Mar - 19
£m £m £m £m £m £m
Total income 365 361 353 355 359 362
Pay Costs (226) (215) (208) (211) (216) (220)
Drug costs (34) (39) (41) (44) (46) (49)
Clinical Supplies & Services (30) (30) (29) (28) (27) (27)
Other Costs (61) (62) (57) (54) (51) (48)
Total costs (352) (346) (335) (337) (340) (343)
Surplus/(Deficit) from operations 14 15 18 18 19 19 Adjustment for donated asset income (1) (1) 0 0 0 0 Earnings before Interest, Tax, Depreciation
and Amortisation 13 14 18 18 19 19
Gain/ (Loss) on asset disposals 0 0 (3) 0 0 0
Interest expense on overdrafts and working
capital facilities 0 0 0 0 0 0
Interest expense on loans and leases (3) (3) (3) (3) (2) (2)
Depreciation and Amortisation (8) (8) (9) (9) (9) (9)
PDC Dividend (3) (3) (3) (3) (3) (4)
Impairment Losses (Reversals) net 22 0 0 0 0 0
Net Surplus/(Deficit) 22.0 0.6 0.3 3.8 4.2 4.3
Table 7: Cost improvement plans 2015/16 to 2018/19 (£000s)
Post completion of OCH capital expenditure post-completion of OCH will return to more ‘normal’ levels.
Cost Improvement Proposals: 2015/16 2016/17 2017/18 2018/19
£’000 £’000 £’000 £’000
Theatre efficiency 500 500 500 500
Reduced Length of Stay 1,000 1,000 500
Reduce premium payments/ outsourcing to private sector 500 500
Skill Mix/staffing review/sickness reduction 2,100 2,000 2,500 2,750
Outpatient clinic efficiency 500
Streamline booking/admin functions 500
Inflation uplifts deliver through efficiency gains + other non pay initiatives
1,000 1,000 1,000 1,000
Private patient strategy 500 500
Income (non-nhs) generation 750 750 750 750
Bank & Agency reduction 500 1,000 500 500
Better Buying 1,500 1,500 1,500 1,500
Use of Technology 500 1,000 1,000 1,000
Income/Coding/Repatriation 1,000 1,000 1,000 1,000
Service Changes/efficiencies 1,000 1,000 1,000
Energy savings
OCH Consolidation Savings 7,500
Clinical Support Services efficiencies 500 500 500 500 Other (incl back office & contingency) 2,950 1,850 3,050 3,500
Table 8: Capital plans 2015/16 to 2018/19 (£m)
The income, revenue and capital expenditure forecasts shown above give rise to the following expected cash flows over the period to 31stMarch 2019.
2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 £m £m £m £m £m £m Maintenance -1.2 -2.3 -3.5 -3.3 -3.6 -3.7 IT -0.9 -1.3 -1.0 -1.0 -1.0 -1.0 Medical Equipment -1.0 -1.3 -1.0 -1.0 -1.0 -1.0 Other -4.3 -1.4 -1.7 -2.2 -2.0 -2.0
Total Operational capital -7.3 -6.3 -7.2 -7.5 -7.6 -7.7
Service developments
SD4 - OCH Consolidation -30.4 -20.8 -3.0 0.0 0.0 0.0
Land tfr from HPFT 0.0 -2.5 0.0 0.0 -6.5 0.0
Donated Asset Capex -1.2 -0.9 0.0 0.0 0.0 0.0
Total capital spend -38.8 -30.5 -10.1 -7.5 -14.0 -7.7
Sources of capital funding
Loans (IBD)
Phase4 drawdown 23.2 1.9 0.0 0.0 0.0 0.0
Bridging loan 12.8 -12.8
Public Dividend Capital 10.8 2.5 0.0 0.0 6.5 0.0
Depreciation excluding donated assets 7.7 7.1 7.7 7.7 7.7 7.7
Land Sale 0.0 0.0 12.8 0.0 0.0 0.0
Donated Assets Funding 1.2 0.9
Other internally generated resources -4.1 5.2 2.4 -0.2 -0.2 -0.1
Table 9: Cash flows 2015/16 to 2018/19
We expect a tight cash position to continue over the next few years. In order to facilitate the FT application we will need to apply for a further £3m FT liquidity loan in 2015/16 to achieve average cash balances closer to Monitors 10 day operating expenditure KPI.
The impact of our financial plans on the Continuity of Services Risk Rating (CoSRR) and old Financial Risk Rating (FRR) are shown in the table below which includes the equivalent metrics for last year and the planned outturn for the current financial year for comparative purposes.
Mar - 14 Mar - 15 Mar - 16 Mar - 17 Mar - 18 Mar - 19
£m £m £m £m £m £m
Includes the impact of inflation
Surplus/(Deficit) from operations 13.8 15.1 17.6 18.0 18.5 18.8
Non cash adjustments -1.2 -0.9 0.0 0.0 0.0 0.0
Operating cash flows before movements in working capital 12.6 14.1 17.6 18.0 18.5 18.8 Movement in working capital:
(Increase)/decrease in inventories 0.0 0.8 0.0 0.0 0.0 0.0
(Increase)/decrease in NHS Trade Receivables -7.9 10.8 0.0 -0.3 -0.1 -0.1 (Increase)/decrease in Non NHS Trade Receivables -0.4 1.7 0.2 0.0 0.0 0.0
(Increase)/decrease in other receivables 0.8 4.3 0.0 0.0 0.0 0.0
(Increase)/decrease in Other financial assets (e.g. accrued inco 0.0 0.0 0.0 0.0 0.0 0.0
(Increase)/decrease in prepayments -9.3 10.8 0.0 0.0 0.0 0.0
(Increase)/decrease in Other assets 0.0 0.0 0.0 0.0 0.0 0.0
Increase/(decrease) in Deferred Income & Payments on account 0.0 -0.1 2.0 0.0 0.0 0.0
Increase/(decrease) in provisions 0.1 -0.2 0.0 0.0 0.0 0.0
Increase/(decrease) in Trade payables 2.0 -0.5 6.2 0.0 -0.1 -0.1
Increase/(decrease) in Other payables -2.6 -3.8 -1.0 0.0 0.0 0.0
Increase/(decrease) in PDC Dividend payable
Increase/(decrease) in accruals 5.8 -18.1 -4.7 0.0 0.1 0.2
Increase/(decrease) in Other liabilities
Increase/(decrease) in working capital -11.5 5.7 2.7 -0.3 -0.1 0.0 Increase/(decrease) in Non Current Provisions -0.1 -0.1 0.0 0.0 0.0 0.0 Net cash inflow/(outflow) from operating activities 1.0 19.7 20.3 17.8 18.3 18.8
Cash flow from investing activities
Property, plant and equipment and intangible asset expenditure -32.9 -33.6 -7.6 -7.6 -14.1 -7.7 Proceeds on disposal of property, plant and equipment and intan 0.0 0.0 10.3 0.0 0.0 0.0 Other cash flows from investing activities
Net cash inflow/(outflow) from investing activities -32.9 -33.6 2.7 -7.6 -14.1 -7.7
CF before Financing -31.9 -13.9 23.0 10.2 4.3 11.2
Cash flow from financing activities
Public Dividend Capital received 15.9 2.5 0.0 0.0 6.5 0.0
Public Dividend Capital repaid -5.1 0.0 0.0 0.0 0.0 0.0
Dividends paid -3.2 -3.5 -3.2 -3.3 -3.4 -3.7
Interest (paid) on loans and leases -2.5 -3.1 -3.1 -2.5 -2.4 -2.3
Interest (paid) on bank overdrafts and working capital facilities
Interest received on cash and cash equivalents 0.0 0.0 0.0 0.0 0.0 0.0
Drawdown of loans and leases 23.2 26.7 3.0 0.0 0.0 0.0
Repayment of loans and leases -2.4 -5.9 -17.6 -5.3 -5.4 -5.3
Other cash flows from financing activities
Net cash inflow/(outflow) from financing 26.0 16.8 -21.0 -11.1 -4.7 -11.3
Taxes paid 0.0 0.0 0.0 0.0 0.0 0.0
Table 10: CoSSR 2013/14 to 2018/19
Risks
Ensuring quality governance and risk management is fundamental to achieving our vision. The process by which we manage risk is illustrated below.
Figure 3: Risk management and assurance process
The process is based on three levels; each division and directorate maintains a risk register; the corporate risk register provides a record of all identified risks to the organisation; and risks to the trust’s strategic and annual objectives are managed through the Board Assurance Framework (BAF). The following table provides a summary of the key business risks facing the trust.
Financial Risk Ratings 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19
Previous FRR methodology 3.0 2.0 2.0 2.0 2.0 2.0 Continuity of Service Risk Rating
(CoSRR) excluding WCF 2.0 2.0 1.0 2.0 2.0 2.0 Liquidity Ratio Score 2.0 2.0 1.0 1.0 1.0 1.0 Liquidity Ratio Days -8.4 -11.5 -23.3 -13.4 -14.0 -14.1 Capital servicing capacity score 1.0 1.0 1.0 2.0 2.0 2.0 Capital servicing capacity (times) 1.0 1.1 0.7 1.6 1.7 1.7
Table 11: Risks
Risk Mitigation
Risk that whole systems plans that have an impact on demand, capacity and finance in this organisation are not fully delivered.
Regular progress reports available to allow effective monitoring. OCH plans factor in flexibility to increase capacity should plans not deliver reductions.
Continue to work with CCG to deliver robust plans for activity reductions. System Programme Board to be established with TDA and NHS England and local partners
Strong clinical engagement on the process of identification of schemes, through joint Trust /CCG workshops, the clinical forum and internal liaison with Directors
Risk of breach of the requirements of the TDA performance framework
Monthly Performance reports and scrutiny of performance; A&E recovery action plan; 18wk speciality action plans and
trajectories.
Infection Control Policies, deep clean programme and audit programmes. Root cause analysis on all cases of hospital acquired infections.
Programme of CQC style quality walkabouts
Fortnightly scrutiny by Executive/Divisional Executive Team and monthly reports to Board and Board Committees.
Risk of delivery of the Financial Plan, surplus and Monitor requirements due to high level of CIP’s, large reconfiguration programme and demand and capacity levels not within Commissioned and planned levels
Strong history of delivery of CIP programme and infrastructure in place – Division to Board
Weekly scrutiny at divisional / Exec level; Monthly scrutiny through FPC and Board
Discussions with CCG on capacity / demand / activity levels Roll out of SLR across all divisions
Risk of failure to embed new teams and ways of working impacting on the delivery of quality improvements, cost of service and ‘business as usual’ workforce targets
Monthly reports on workforce efficiency data to Board committees on floodlight score card and exception reports. Workforce plans within OCH and support IBP. Trust and Divisional workforce action plans.
Development and implementation of the Trust Organisation Development Strategy including the ARC programme. Leadership programmes; Education and training support Staff survey and FFT
Risk Mitigation Risk that service pathway changes and
changes to the coding service model do not deliver the reductions in mortality set (particularly in SHMI).
Monitoring of mortality at Trust, Divisional and Consultant Level, including 100% mortality reviews; Regular reports to the Risk and Quality Committee (RAQC), Board and CCG; Clinical Audit Programme. Care pathway reviews
HSMR/SHMI benchmarking reports. HSMR/SHMI action plan agreed; Mortality outlier investigation reports and actions. Improvement in depth of coding and monthly monitoring to ensure further improvements are made and sustained; Regular coding and mortality meetings.
Implementation of Keogh recommendations and plans for 7 day working
Joint reviews of out of hospital deaths (within 30 days) Risks to business continuity and
improving quality of services at MVCC due to specific estate and infrastructure risks and lack of engagement by HHT in seeking mutually agreeable solution
Regular Mini Board to Boards with ENHT & HHT; Joint MV2015 Project Board; Joint MV Governance Board
Review of business continuity plans and monitoring of actions following recommendations of external bodies/reviews SLA negotiations
Risk of failure to meet the expectations of patients, carers and other key customers (GPs)
Patient and Carer Experience Strategy
Nursing and Midwifery Strategy incorporating the ‘Six Cs’ Engagement Strategy and programme of involvement ARC programme
Quality and staffing metrics at ward level
Programme of audits with links to National Patient survey, PLACE and local priorities. Results reported and monitored through Divisional Performance reviews.
Programme of Quality and Safety Audits Patient, Carer and GP Forums
Patient experience reports to RAQC & CCG. Primary Care Relationship Manager Risk that current IM&T infrastructure will
not fully support the technological changes required for future service delivery/change
Review of IM&T strategy and structure with support of consultants
IM&T Strategy Group with Clinical engagement
Transforming Inpatients Management Programme, Transforming Outpatient Management Programme and Telehealth Group Bids to central and local funding streams include clinical leadership and engagement.
Leadership and workforce
Strong visible leadership of the Trust Board is provided by an experienced Chairman and Chief Executive. They are supported by an experienced and diverse team of executive and non-executive directors.
Clinical services are organised into five divisions - medicine, surgery, cancer and, women’s and children’s, supported by the clinical support division (providing pathology, radiology, pharmacy and other support services). Each division is led by a Divisional Chair and Divisional Director, with a senior nurse and dedicated support from corporate services. Our clinical divisions are supported by a range of corporate services.
We currently directly employ approximately 4,700 w.t.e. staff. The five year workforce plan takes account of the impact on the shape, mix and size of the workforce through the delivery of the planned service developments and the cost improvement plans. We also run a well-established organisational development programme, ARC, which seeks to embed our stated values and culture throughout the trust.
Governance
The Trust is led by the Trust Board beneath which sits our executive committee. The Board has three committees to discharge its responsibilities on assurance:
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Audit Committee•
Risk and Quality Committee (RAQC)•
Finance and Performance Committee.Figure 4: Board and committee structure
There is strong Board governance, including formal meetings and seminars. The Board Assurance Framework (BAF) incorporates the corporate risk register. The BAF is a live document with ongoing work to strengthen the controls, actions and links to known future sources of internal and independent assurance. Updates are reported at public Board meetings.
In line with our ambition to be amongst the best and become a leading FT we have implemented a
revised performance management framework based on the recommendations of The Intelligent Board. Bi-monthly performance meetings are held with each division.
The Trust Board has implemented a work programme (the Board Cycle) to ensure that all items that require discussion/approval/decision are properly scheduled. The Board receives the following reports during the course of the year:
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A detailed compliance report based on the CQC standards and Monitor’s compliance framework, the output of which determines the governance risk rating (monthly)•
Finance reports, including a detailed evaluation of the financial risks facing us (monthly)•
Reports and minutes of the Trust Board Committees (monthly)•
Board Assurance Framework•
Corporate Risk Register (reviewed quarterly by the RAQC and at least annually by the Trust Board)•
In-depth reviews on a regular basis of clinical quality, patient experience, patient safety, staff and patient surveys, clinical efficiency, and the organisational development, and quality strategies.In anticipation of FT status we are ensuring our growing membership is representative of the communities we serve. We have nearly 11,000 members. Our constituencies, and therefore our governor representation, reflect our patient flows and recognise recent changes to our commissioning bodies and successor organisations.
Foundation Trust status
We believe that as an autonomous FT we will be better placed to achieve our vision and to deliver the transformed services needed to respond to the changing needs and priorities of our community. The key benefits of FT status that we envisage are:
