Operational Plan - dchft.nhs.uk · PDF fileDorset County Hospital NHS Foundation Trust...

Operational Plan

2017 - 2019

Dorset County Hospital NHS Foundation Trust Operational Plan 2017 - 2019 2

Introduction

We are pleased to present the Dorset County Hospital NHS FT Operational Plan Narrative

for the period 2017/18 to 2018/19.

In the following pages we have summarised our approach to activity, workforce, quality and

financial planning. Additionally we have set out how these plans are aligned to the Dorset

Sustainability and Transformation Plan. Finally we provide an update on our Trust

membership.

Further to our Draft Operational Plan submitted on 24th November 2016 we have received

the feedback from NHS Improvement and have endeavoured to amend our plan accordingly

and appropriately. We have also provided an addendum to this plan narrative which sets out

our responses to the feedback received from NHSI on 16th December 2016.

In particular we have noted the feedback that the plan does not align with the ambitions of

the Dorset STP and clinical services review to reduce activity within acute settings.

The first two years of STP planning is aimed at reducing demand and reversing historical

growth seen in Dorset, this will allow organisations to free up capacity and reduce costs to

enable transformational changes in years 3-5 as identified in the STP and as part of the

Dorset CSR.

We expect the programmes outlined in our plan to be the start of delivering changes that will

reduce activity in hospitals and move the system towards the strategy outlined in the STP for

greater care outside of hospital delivered in a more integrated way with social care. Senior

Responsible Officers have been identified for these programmes and for the first time

system-wide groups of medical, operational and finance executives will be leading on

delivering the plans.

We are supportive of the CCGs plans set out in the CSR and actively engaged in developing

and delivering the key critical transformation programmes required for the delivery vehicles

for the CSR and STP.

We are absolutely committed to doing all that we can to deliver safe, high quality services

and the agreed access standards for patients within the resources available to us. We are

also resolute in our desire to work as part of the Dorset health and care system to deliver

sustainable, transformed services which meet the three gaps identified in the FYFV to the

benefit of our patients and communities.


1. Approach to Activity Planning

Dorset County Hospital NHS Foundation Trust’s (DCH) business plans are based on delivering the anticipated levels of demand in line with national quality and performance standards in the most cost efficient manner. Robust activity planning is therefore core to the development of the plan. During 2016/17 the Trust has experienced continuing growth in its elective workload, although this is for Day Case activity as opposed to Elective Inpatient activity. The level of referrals for the acute and general activity has remained mainly flat, although does fluctuate between months. The emergency workload including emergency admissions and A&E attendances has continued the growth seen in previous years. Outpatients have seen a drop in total activity mainly around Follow Ups especially in Ophthalmology and General Medicine, New Outpatients have grown but at a lower rate than previous years.

For the current planning round the Trust has planned activity levels by working closely with the clinical teams working through demand and capacity using a simple spreadsheet model which also includes additional information on referral trends and any in year developments.

The overall growth for elective care includes some additional activity to clear backlogs which is not expected to be required going forward, therefore with this reduction and the plans being developed with the CCG as part of the Dorset Clinical Services Review and Dorset Sustainability and Transformation Plan it is expected that the current activity levels are maintained until the implementation and traction of any CSR/STP initiatives. Growth of 5.3% was seen in non-elective activity in 2016/17 and similar should be expected in 2017/18, although the setting for treatment may change to ambulatory rather than inpatient stay.

As part of the approach taken by the Trust’s main commissioner demand growth above outturn has not been included in the contracts. As part of the STP it has been agreed that a joint approach needs to be taken to hold demand levels at the current levels. This work is still being developed into detailed plans and includes areas such as an expansion of the Low Priority Procedures list, referral management schemes, advice and guidance schemes, reduction in variation through Right Care, Get It Right First Time (GIRF) and improved urgent care pathways. Included in 2017/18 plan, as part of the STP, is the transfer of responsibility for the Community walk in centres, this is to enhance the clinical relations and support the flow of patients.

2015/16 Outturn Activity

2016/17 Forecast Outturn *

2017/18 Plan

2016/17 Growth

(%)

2017/18 Planned

Growth (%)

Elective 25,911 26,839 27,024 3.5% 1%

Non Elective 20,958 22,086 22,186 5.3% 0%

Outpatients 178,366 176,637 177,516 -1.5% 0%

Emergency Department

44,110 45,640 103,164 3.5% 126%


Alongside the use of the spreadsheet models the Trust has continued to use dedicated demand and capacity tools.

The Directorate/Specialty Managers have attended a one day workshop with NHS Improvement using the IMAS models to demonstrate good capacity and demand modelling. Further training for operational level support will be made available via Webinar later this year. The Trust has invested further in a demand and capacity system. There has been a phased approach to the implementation, starting in 2015 with the surgical specialties then moving onto the medical specialties. Diagnostics will also be independently modelled using this approach so that the Trust can view a whole model of capacity and demand. Some of the early outputs have been used to support the planning figures, predominantly in the surgical specialties.

The demand and capacity modelling highlights that there will not be a requirement to go out to the independent sector to purchase additional capacity in 2017/18.

The Trust has undertaken regular internal reviews of pathways for cancer patients and is working in partnership with the Dorset Cancer Partnership and Wessex Cancer Alliance to ensure patients have equity of access across the region. The Trust continually reviews available capacity to meet the agreed timed pathways in place for each tumour site. The Trust is working other Acute Trusts in Dorset on a pilot, hosted at the Royal Bournemouth, to test out pathways which support 28 days to diagnosis which will replace the Two Week Wait referral process by 2020. Treatments for complex conditions which take place at tertiary centres as part of an agreed network pathway have presented challenges to the local acute health care providers in-year and the Trust is working closely with those providers to agree sufficient capacity is available to treat all patients within 62 days of referral. A new Beach Reallocation Policy was launched in October 2016. Dorset Trusts have agreed to work on pathways together using breach analysis rather than use the reallocation mechanism. Tertiary centres in greater-Wessex have indicated a lack of enthusiasm for the Re-allocation Policy implementation but the Trust remains alert to the potential for re-allocation of breaches to impact adversely on the Trust’s ability to meet the 62 Day Standards.

The Trust has implemented its multi-layered winter plan which included increased use of ambulatory care; medical and surgical assessment units; continued development of Discharge to Assess models, supported by a network of Trusted Assessors/Professionals; embedded learning from an internal waits audit carried out in the year which indicated early clinical decision making and agreed/timed discharge planning processes; implementation of advanced IT systems to support visibility of discharge planning; multiple supported discharge models working in partnership with other healthcare providers; and turning ‘flex’ beds into established capacity with sufficient substantive staff which will assist in improving staff and patient experience and lead to a reduction in length of stay. This plan has improved the safety and effectiveness of the Trust’s winter plan.

Based on the above approach to activity planning the Trust is confident in its ability to achieve the national performance standards.


2. Approach to Quality Governance

As part of the standards for patient services detailed within the NHS Constitution and the CQC’s fundamental standards of quality and safety, the Trust is committed to the provision of safe, high quality care and improving its current CQC rating from ‘Requires Improvement’ to ‘Outstanding’.

A CQC Inspection was undertaken March 9-11 2016. A full action plan has been developed and is in the process of being finalised with the CQC.

The Trust commissioned an independent review of its governance processes which highlighted the need for more structured visibility of quality and safety metrics from ‘Ward to Board’. The Trust is currently in the process of reviewing its clinical divisions to ensure that they serve the needs of patients, the community and are sustainable and effective. Once completed the new divisions will have clearly defined roles and responsibilities in providing assurance of governance processes.

2.1 Quality Improvement

The Trust has invested and created a permanent service improvement team. The team identifies, supports, delivers and manages improvement initiatives generated from across the Trust, including; ideas from staff; benchmarking information; projects identified through the Better Value Better Care programme; and direction from the Senior Management Team.

The Trust has developed a Continuous Improvement Strategy which can be made available on request. The Trust improvement methodology is borne from NHS LEAN, NHS Improving Quality and Institute for Healthcare Improvement’s triple aim. The Trust has also recently been working in conjunction with NHS Elect to deliver training and coaching to over 400 of its senior leaders in a series of 3 day events to help staff understand the wider context of the health and social care services in which they work, to understand how they can influence changes and finally to provide them with the tools required to drive continuous quality improvement. These improvements, driven by frontline staff with corporate support are anticipated to help the Trust achieve a good/outstanding CQC rating. The impact of the quality improvements undertaken will be measured through the key performance indicators, reductions in clinical incidents and feedback received from our patients and their families.

Service Improvements are governed by a committee called The Better Value Better Care Board; chaired and attended regularly by executives, senior managers and clinicians. This committee approves new initiatives, receives progress updates about on-going work, assesses their impact on quality and safety and gives direction.

The Quality Account priorities 2016/17 were selected by the Trust and built on the top risks to quality identified internally as well as reflecting the National and Local commissioning needs. The Trust reports on these quarterly both internally and to an external Dorset Health Overview Scrutiny Committee.

The National CQUINs for 2017-2019 have recently been published and identify 7 key mandated CQUINs for acute providers, with no local CQUINs for this time period.

Robust analysis of

Mortality and SHMI

outlier data

Effective management

of those patients

admitted with

Sepsis/AKI (CQUIN)

Medicines

management

Standardisation of

equipment, procedures

and pathways where

appropriate

Reducing Hospital

Acquired Pressure

ulcers

Improved mortality

surveillance and

reducing variation

Timely and accurate

provision of Electronic

Discharge Summaries

to primary care

Improving compliance

with NICE Guidance

Improving services for

Children and Younger

People

Improving breast

feeding rates within

maternity services

Helping patients to

manage risky

behaviours such as

smoking and

alcohol(CQUIN)

Implementation of

Carter

recommendations

(Effective rostering)

Improved data

intelligence and

transparency

Improved analysis of

patient outcome data

Embedding of robust

Governance

processes across

divisions

Effective workforce

planning and

development of new

roles to meet needs

of patients

Implementation of

improved discharge

processes(CQUIN)

Offering advice and

guidance to our

patients(CQUIN)

Coding of specific

incidents or complaints

to improve End of life

Care

Reduce waiting times

for patients and

improve e‐

referrals(CQUIN)

Ensure principles of

the NHS Constitution

are applied

Implementation of

‘Seven Day Services’

Improving services for

patients with Mental

Health and Learning

Disabilities(CQUIN)

Advanced

communication skills

for staff supporting

patients and families at

End of Life

Improving accessibility

of information to

patients

Timely and

compassionate

response to complaints

Promoting the health

and wellbeing of our

staff – including

healthy food (CQUIN)

REDUCING UNWARRANTED VARIATION IMPROVE INFORMATION ACCESSIBILITY, INTELLIGENCE AND TRANSPARENCY TO DRIVE

QUALITY

SAFE AND EFFECTIVE ACCESS, ADMISSION, TRANSFER AND DISCHARGE

EXECUTIVE LEADS: Paul Lear (Medical Director) and Nicky Lucey (Director of Nursing and Quality)

SAFE EFFECTIVE WELL‐LED RESPONSIVE CARING


2.2 Quality Impact Assessment Process

It is essential for the Trust that all opportunities for improving efficiencies are identified and delivered in a manner that allows sustainable change and allows the Trust to continue to provide high quality, compassionate care for future generations.

The Trust recognises that radical redesign needs to occur if efficiency and productivity are to be optimised and efficiencies delivered. A Better Value Better Care programme has been developed within the overall aim of driving service improvement to achieve maximum benefits whilst improving quality and efficiency. The development of the savings programme is an iterative process and the Better Value Better Care Board ensures best practice is being reviewed and embedded on a continual basis. There are 3 key areas where efficiencies are identified:

Health economy wide: Dorset CCG is leading on a Clinical Services Review across Dorset which will lead to a financially sustainable model being identified. DCH is part of this review and requires the outputs of it to drive forward the service models required. DCH is part of the One NHS in Dorset acute care collaboration Vanguard project and through this work efficiency improvements will be identified and delivered. DCH is part of a project in the west of Dorset working on integrating acute and community healthcare;

Trust wide schemes: Each service is expected to use benchmarking data to identify where productivity gains can be made. The sources of data include NHS productivity indicators, internal service line reporting data, external reviews i.e. Carter, ERIC, NHS benchmarking. Each division has developed its own CIP governance model to ensure this approach is embedded in each service; and

General efficiency improvement: The Better Value Better Care programme was launched across the organisation with awareness raising events held. All staff are encouraged to look for ways to improve efficiency and discuss ideas with the service improvement team.

The proposed plans for each service are reviewed and agreed through the annual business planning process. For clinical transformational schemes the Service Transformation Board agrees and monitors them to ensure time and clinical input is given to assessing the impact on quality. The Better Value Better Care Board has an overview of all CIP programmes to ensure strong governance.

Commencing alongside the business planning process for this year is the introduction of a Quality Impact Assessment for any CIP with a value of over £25,000 (or combined small CIP’s with a value exceeding this value). This has been developed to provide assurance that the efficiencies described within the CIP will have no detrimental consequence to either patient safety or patient experience.

The trust will utilise Governors and Non-Executive Directors in ‘Back to floor’ visits to provide additional assurance on any cumulative impact of schemes on a pathway, service, team or professional group.


2.3 Triangulation of Indicators

An integrated performance report is produced on a monthly basis to the Board of Directors. This report is a summary of key quality, workforce and financial risks to enable the Board to triangulate these risks. The key indicators have been aligned to the 5 domains of the CQC, and subcommittee responsibility of monitoring and scrutinising of these indicators has been established. They cover the following:

Quality and Operational performance standards: These include the national operational standards i.e. access times and the national quality requirements i.e. infection control , VTE, cancelled operations, duty of candour, delayed discharges, stroke standards, pressure ulcers, never events, family and friend test results. A comprehensive list is reviewed each month.

Workforce: Includes appraisal rates, turnover, sickness, essential skill training rates, staff survey key questions. The key indicators are agency rates and compliance against national expectations on agency caps, rostering efficiencies; and

Finance: Includes the financial risk rating, surplus, CIP delivery, capital spend, liquidity, agency spend. The key indicators are reduction of the current deficit and liquidity.

This information is presented to the Trust Board for assurance, after receiving full scrutiny in the relevant sub-committees of the Board. The sub-committees utilise the information in order to be able to identify any areas in need of further development and to allow for direct Executive Director support in areas which consistently do not achieve the standards required.


3. Approach to Workforce Planning The Trust has embedded workforce planning into the business planning cycle. Business plans are developed in the context of:

● Known commissioning intentions ● Outputs from the Acute Vanguard and Dorset Clinical Service Review ● Alignment to the Dorset STP ● The review of unsustainable services ● Meeting the requirements of the Lord Carter Review recommendations ● Required cost improvement targets ● Health Education England guidelines

The planning cycle requires input from all key stakeholders including commissioners, clinical leads, heads of service, senior management, finance and human resources. Workforce planning within Dorset is taking a system wide approach which gives local and national context, provide details of the existing workforce and identify gaps in current and future workforce demand. Specifically, future planning cycles will be conducted collaboratively, under the oversight of the Dorset Workforce Action Board, Chaired by a Provider Chief Executive and represented by all Providers and the CCG, to underpin the delivery of the STP, CSR and Acute Vanguard programmes. Workforce plans are developed with the support of HR Business Partners and are assessed in the context of workforce supply, retention and demand. Changes to workforce models are assessed in the context of national guidelines and are reviewed to assure patient experience and outcomes meet expectation. Leadership Development Programme 2016 In support of the business planning process the Trust has provided a leadership development programme to all staff within Band 7 and above (including Medical colleagues). This programme provides a comprehensive understanding of the key requirements of Dorset STP, Acute Vanguard and Clinical Service Review. The programme focuses on the values and the behaviours necessary to achieve a step change in effective collaborative working, and a focus on developing a culture of continuous quality improvement. Key changes to the Workforce in 2017-19 Managing Agency and Locum Usage - a comprehensive plan is underway to help manage and reduce the use of agency staff. Key elements of this plan include:

● Governance Process – the Trust has established robust Executive-led controls for the approval and review of agency usage. All high cost, long-term agency cover requires approval by two Directors. Agency usage is reported in detail on weekly basis to the Senior Management Team and on a monthly basis to the Trust’s Finance and Performance Committee, Trust Board and Resourcing Strategy Board. The Resourcing Strategy Board is accountable for developing recruitment plans and alternative delivery models to minimise/negate the use of agency staff


● Nursing - the Trust will continue to recruit further bank, relief pool and substantive staff to help minimise the use of agency staff. Recruitment trajectories and plans to reduce the nursing vacancy gap are reviewed within the Trust’s Resourcing Strategy Group and Better Value Better Care Board. A review of beds capacity in Medicine and improved management of the rostering of annual leave will reduce overall demand.

● Longer term we anticipate a migration of nursing activity from Acute to Community settings. The Trust recognises that attrition rates are rising within the registered nurse workforce largely through increased retirements. Plans are underway analyse the underlying causes of attrition and to develop new roles, training programmes and working patterns to help retain staff throughout their careers.

● Allied Health Professionals - building upon the Trust’s success in reducing nurse agency usage, the Trust is developing a comprehensive recruitment programme for allied health professionals. The programme will include collaborative recruitment with community trusts to offer rotational contracts.

● Medical - the Trust will fully implement the recommendations of the “Reducing reliance on medical locums: a practical guide for medical directors”. Long-term substantive vacancy gaps within medical posts presents the highest risk of ongoing agency costs at the Trust. The Trust is now working with advertising, social sourcing, overseas recruitment and search providers as part of an ongoing plan to reduce the medical vacancy gap. Where workforce supply does not meet demand the Trust plans to introduce new models of care including the use of physician’s assistants, and advanced nurse practitioners to contribution to middle grade rotas and develop more nurse-led clinics.

● Specifically the Acute Vanguard will result in the reshaping of the clinical workforce models for women’ health, paediatrics, cardiology, stroke, ophthalmology, non-surgical cancer services, imaging and pathology. This work will result in a reduction in long-term, high-cost agency usage.

● Pan-Dorset Workforce - the Trust aspires to the development of a shared business services centre within Dorset to facilitate workforce planning, recruitment and temporary staffing. In the short-term trusts in Dorset will take steps to introduce contractual frameworks that allow an employee to be recruited (cleared) once, trained once and work across all trusts in the county.

Apprenticeships - a revised Apprenticeship Policy will be reviewed in December 2016. The use of apprentices within a wider range of settings will now form part of the workforce plan. New areas to offer training will include:

● Estates and Facilities; Catering; Domestics; Portering ● Health Care Apprentices

Workforce plans will include the establishment of a number of recurrently funded apprenticeship roles to help embed apprenticeships as the preferred recruitment method. Typing and Secretarial Services - Clinic typing and secretarial services (Apprenticeship to Band 4) will be reviewed as part of a larger project involving the roll-out of updated voice recognition and digital dictation technology. It is anticipated that this will release efficiencies during 2017-19.


Band 3 and Band 4 Assistant Practitioners - It is not yet possible to assess the impact of the removal of bursary payments however the Trust anticipates no easing in the recruitment challenges for registered nursing and therapies staff. Where appropriate, new models of care and skill mixes will be developed to reflect the participation of Band 3 and Band 4 staff. Collaborative working – the Trust are fully engaged in the delivery of a number of collaborative opportunities detailed in the STP. During the 2017-19 planning period we will see workforce developments as part of a delivery of a number of schemes, including:

Business Support Services pan Dorset review Pathology services review Acute Hospital clinical services review (Acute Hospital Vanguard collaboration) Integrated Community Services review

4. Financial Planning

4.1 Financial Forecasts and Modelling The Trust has been allocated £4.176 million of funding from the Sustainability and Transformation Fund (S&T Fund) for each of the financial years 2017/18 and 2018/19. The control total allocated (including the general element of the S&T Fund) for 2017/18 is a £2.906 million deficit and for 2018/19 is a £1.292 million deficit. The Trust has taken advantage of the flexibility for 2018/19 control totals (as it is forecasting to achieve its 2016/17 control total and is signing up to the 2017/18 control total). Therefore, the Trust has included a revised control total for 2018/19 in its operational plan of a £2.75 million deficit. In order to achieve these positions a CIP of £10.3 million (6.1%) will have to be delivered in 2017/18 and £5.3 million (3.1%) in 2018/19. The reason for this level of CIP is as follows:

The planned position for 2016/17 is a deficit of £1.8 million, however the underlying deficit is £7.1 million. The difference of £5.3 million is due to: £4.1 million of CIP forecast to be delivered non-recurrently in 2016/17 (this includes schemes which have yet to be identified and therefore we anticipate further schemes will become recurrent and reduce this amount); £700,000 of full year effect recurring cost pressures; and £0.5 million reduction in S&T Fund allocated. The control total allocated for 2017/18 has increased slightly to £2.906 million, so the difference between this and the underlying deficit creates a financial pressure of £4.2 million;

Inflationary pressures are £1.8 million above the assumed efficiency factor of 2% (£3.2 million). These relate to CNST costs increasing above tariff funding; and increments being an increase in cost to the Trust due to a low turnover of staff whereas the tariff assumes a reduction in incremental costs; and

For 2016/17 we have development costs of a minimum of £900,000, which are essential for maintaining safe services. These are in response to the recommendations made following the Trust’s CQC inspection in March 2016, and relate to increasing the number of nursing staff on wards, especially at night, winter escalation pressures and increasing midwife numbers to comply with national midwife to birth ratios. The increase in 2017/18 represents the full year effect of the increased staffing levels implemented in 2016/17.


The above totals £6.9 million of pressures (for 2017/18) which increases our CIP to £10.3 million (6.1%), which will represent a significant challenge to achieve without compromising the safety and quality of patient services. A ‘whole health system’ response is required in order to achieve this scale of efficiency over the next two years and so the Trust is working closely with its partners in the development of and plans for implementation of the Dorset wide STP. On this basis the Trust is accepting its control totals for 2017/18 and 2018/19 and is submitting an operational plan that meets the required financial control totals for the two years and the Trust Board agrees to the conditions associated with the S&T Fund.

There remain considerable risks to delivering the control totals each year, mainly due to the fact that the majority of efficiency savings required need to be delivered through a Dorset system-wide approach. As the realisation of savings from the schemes being taken forward through the Dorset STP have not yet been agreed there remains a significant risk that the required level of savings will not be achieved in the necessary timescales. In addition, there will be elements of the system wide schemes that will be out of the control of the Trust.

Other risks to the delivery of the control totals in 2017/18 and 2018/19 are as follows:

Dorset CCG does not have the funding available to pay for the level of activity being experienced;

The operational plan assumes no increase in Dorset CCG funded activity over the two years, which will require significant commissioner led demand management;

The level of CIP required to be delivered is currently not considered to be achievable.

Despite planning to meet its control totals for each of the next two years, the Trust will require formal cash support from June 2017 onwards, on the basis of the deficits being incurred.

The Trust’s forecast outturn for 2016/17 is a deficit of £1.8 million, which is in line with the control total for the year. This forecast includes the full £4.7m of S&T Fund allocation for 2016/17, and so assumes the Trust achieves all of its S&T Fund targets. There are a number of significant risks relating to the ability of the Trust to achieve its control total by the end of the financial year as follows:

Achievement of STP for delivering access standards; Delivery of the £6.7million CIP – current gap of £800,000; Achieving contracted levels of activity and associated income; and Demand increases over the winter period;

A financial recovery plan has been developed and its delivery is being led by the Finance Recovery Team to ensure the control total is met at the end of the financial year. If the above risks are not mitigated the deficit could increase to between £4 million and £6 million. The trust remains focussed on the delivery of its recovery plan in order to achieve the £1.8 million target deficit.


The table below summarises the forecast position for 2016/17 and the planned position for 2017/18 and 2018/19:

2016/17

Forecast - £m

2017/18

Plan - £m

2018/19

Plan - £m

Operating Income from Patient Care Activities

149.456 152.729 154.930

Other Operating Income 17.093 17.005 17.822

Operating Income 166.549 169.734 172.752

Employee Expenses (107.122) (108.446) (108.370)

Non Pay Expenses (58.449) (61.331) (64.266)

Operating Expenses (165.571) (169.771) (172.636)

Operating Surplus/(Deficit) 0.978 (0.043) 0.116

Non-Operating Income 0.094 0.010 0.010

Non-Operating Expenses (2.868) (2.871) (2.874)

Surplus/(Deficit) (1.796) (2.904) (2.748)

Memorandum information

CIP/Revenue Generation (netted above) £m

6.7 10.3 5.3

4.2 Income The 2017/18 and 2018/19 plan figures are based on the Trust’s business planning process and the most up to date contract discussions with each Commissioner. The above activity forecast underlines the proposed commissioning contracts for 2017/18 and 2018/19. The Trust has a number of commissioning contracts in place as follows:

Dorset CCG – the main contract is with Dorset CCG who commission on behalf of the Dorset population. The contract values for 2017/18 and 2018/19 have been agreed between the Trust and Dorset CCG. The contract value for 2017/18 is a ‘flat cash’ position based on the amount forecast to be received in 2016/17, and for 2018/19 a 1% increase has been included. The contract figures also include the transfer of services relating to the Identification Rules exercise for Specialist Services. Heads of Terms are currently being agreed across Dorset as a system wide approach is being taken to managing the financial risks. The Heads of Terms have been agreed in principle with further work required on the detailed deliverables of each of the work programmes. No further funding will be available for an increase in activity and a number of demand management work programmes are being developed in order to manage this risk.

NHS England - Contracts are held with NHS England for specialist services, military work, prisons and dental. The contract values included within this plan are based on the 2016/17 forecast out-turn positions updated for the impact of the new (HRG4+) tariff and the Identification Rule changes referred to above. The contract values for Specialist services, military work, prisons and dental activity have been agreed. The Trust has assumed (on the basis of the discussions to date with the NHS England contract team) that it will be paid for actual activity delivered in 2017/18, irrespective of the contract value;


Somerset CCG - commissioning on behalf of the Somerset population. The contract

value included in the plan is based on the forecast out-turn for 2016/17. The contract values for 2017/18 and 2018/19 has been agreed with Somerset CCG; and

Local Authorities - commissioning Public Health Services. The Trust has been notified that the Local Authority will be applying a 6.9% reduction to the contract values for both 2017/18 and 2018/19, which are the figures included in the operational plan. The contracts are ‘blocked’ through Dorset County Council rather than being based on actual activity.

As noted above the £4.176 million of Sustainability and Transformation funding allocated by NHS Improvement for 2017/18 and 2018/19 has been included within the plan. The amount allocated is lower than that for 2016/17 at £4.7 million. The Trust is not anticipating significant movements in other income in 2017/18 or 2018/19, other than in private patient income, where the impact of the new commercial strategy is expected to deliver increased activity over the period of the operational plan.

4.3 Costs

The process for identifying future year costs has been through the Trust’s annual business planning framework which is predominantly activity and risk driven. It is anticipated that costs will increase by £14.1 million in 2017/18 and £7.2 million in 2018/19 as shown in the table below:

2017/18

Cost Increase - £m

2018/19

Cost Increase - £m

Inflation (pay, non-pay & capital charges) 4.3 3.1

Developments/Risk mitigation 0.9 -

Service Changes (Income Offset) 2.2

Impact of CNST changes 0.7 0.8

Increase in non tariff drugs costs 0.8 0.5

Full year effect of prior year changes 1.0 -

Non recurrent CIP in prior year 4.1 2.8

Total 14.1 7.2


Assumptions made in the above cost increases are as follows:

Inflation – pay inflation includes pay awards based on the anticipated pay offer for 2017/18 and 2018/19, incremental drift, and the impact of the Apprenticeship Levy. Non pay inflation includes the anticipated price increases on supplies, services and Clinical Negligence Scheme for Trusts (CNST), together with the increased cost of capital. The following inflation assumptions have been made:

2017/18

Cost Increase %

2018/19

Cost Increase %

Pay – Inflation 1.0% 1.0%

Pay – Incremental Drift 1.2% 1.0%

Pay – Apprenticeship Levy 0.5% -

Non Pay 2.1% 2.1%

CNST 12.5% 12.5% Financial pressure – the Trust is facing cost increases in 2017/18 of £5.0 million as a

result of inflationary increases in pay and non-pay (including CNST). This compares with the assumed efficiency target of 2% (equivalent to £3.2 million) and the ‘flat cash’ position included on the main commissioning contract with Dorset CCG, resulting in a cost pressure to the Trust of £1.8 million. This is mainly due to incremental progression costs higher than those allowed for in the efficiency factor (as a result of the age and turnover rates of staff) and the increase in CNST costs with no increase in contractual income;

Service developments/Investment in quality – in response to its financial position the Trust has only included the minimum amount of development funding in its operational plan and therefore has included £900,000 in 2017/18 and nothing in 2018/19. The costs included are essential for maintaining safe services. These are in response to the recommendations made following the Trust’s CQC inspection in March 2016, and relate to increasing the number of nursing staff on wards, especially at night, winter escalation pressures and increasing midwife numbers to comply with national midwife to birth ratios

Service Changes (Income Offset) – the Trust has included £2.2 million of costs relating to the transfer of responsibility for the Minor Injuries Units in West Dorset from Dorset Healthcare (offset in full by additional funding from Dorset CCG) and additional funding from Dorset CCG to cover the expected impact of the NG12 recommendations from NICE;

Workforce – the increases in WTEs included in the plan in April 2017 relate to the

service developments summarised above and the assumption that vacant posts in 2016/17 will be filled in 2017/18. The reductions in WTEs in July 2017 relate to the CIPs phased in from that month and the assumed decrease in agency over the summer months. The reduction in agency WTEs then reverse in January 2018.

Efficiency Projects – the Trust is planning a programme of CIPs and revenue generation schemes amounting to £10.3 million for 2017/18 and £5.3 million for 2018/19. The Trust has strengthened the governance framework surrounding the delivery of efficiency across the Trust through the Better Value Better Care Board. Further details are given in the efficiency section below.


4.4 Liquidity The Trust regularly reviews and updates its liquidity strategy to ensure the continuous improvement of the cash position, while supporting the capital investment programme. The Trust has a loan of £4.6 million from the Independent Trust Financing Facility (ITFF), which is due to be repaid in March 2021.

The deficit position in 2016/17 and the planned positions for 2017/18 and 2018/19 are being managed by delaying the repayment of the loan, reducing capital expenditure and utilising existing cash balances.

At 31 March 2017 the Trust is forecasting to have a cash balance of £2.330 million. As a result of the deficits anticipated in 2017/18 and 2018/19, the Trust will run out of cash in June 2017 and will require £5.5 million of Interim Funding Support during 2017/18 (of which £3.0 million will be repaid in year). The Trust will then require a further £6.0 million during 2018/19 (of which £3.0 million will be repaid in year). The working capital element of this funding support has been included within current liabilities in the Statement of Financial Position in the operational plan and the balance (the deficit related funding support) is included in long-term liabilities.

The table below highlights the opening and closing cash position as set out in the plan.

2016/17 2017/18 2018/19

Opening Cash Balance 4.018 2.330 1.161 Closing Cash Balance 2.330 1.161 1.023 DH Revenue Funding Received - 5.500 6.000

DH Revenue Funding Repaid - 3.000 3.000

4.5 Financial Plan Risk Rating

For 2016/17 the Trust has a Financial Risk Rating of 3 as a result of the level of deficit being incurred in the year. The Operational Plan assumes the Trust achieves its financial control totals for each of 2017/18 and 2018/19 with a resultant Financial Risk Rating of 3 for both years. The table below highlights the key figures within the risk ratings for the years covered by the plan:

2016/17 2017/18 2018/19

Capital Service Capacity Rating 2 4 4

Liquidity Rating 2 3 3

I & E Margin Rating 4 4 4

Variance from Control Total Rating 1 1 1

Agency Rating 1 1 1

Overall Financial Risk Rating 3 3 3


4.6 Downside Modelling

The Trust has undertaken financial modelling of the downside risks inherent within its plan for 2017/18 and 2018/19.

Primary Risk Mitigation and ManagementDelivering sufficient CIP to meet the financial challenges

Capacity and capability of service transformation skills to be increased to deliver this level of savings.

Managing demands on our services Working closely with Dorset CCG as part of the STP to develop demand management strategies.

High usage of temporary locum and agency staff due to recruitment difficulties

Controls and governance.

Increase in delayed discharges requiring additional capacity to be opened

Winter plan discussions with Commissioners. Maximum exposure estimated at £1million.

Achievement of CQUIN delivery targets Contract monitoring arrangements in place.

The impact of these risks is that they would reduce the Trust’s Financial Risk Rating to a 4 and mean that further Interim Support Funding was required to manage the consequent cash shortfall.

4.7 Efficiency Savings for 2017/18 and 2018/19

The Trust continues to be required to deliver significant savings to ensure it is financially sustainable, which represents a significant challenge to achieve without compromising the safety and quality of patient services. A ‘whole health system’ response is required in order to achieve the required scale of efficiency over the next two years and so the Trust is working closely with its partners in the development of and plans for implementation of the Dorset wide STP. The details of this and the critical transformation programmes being taken forward are included later in this document. The details of how these projects will impact on the Trust are still being developed and so it is not yet clear exactly what savings will be realised by the Trust over the next two years. As a result a substantial proportion of the savings target for 2017/18 remains unidentified and, if the planned benefits of the STP are not realised sufficiently quickly, this will prevent the Trust from achieving its control total for 2017/18 and 2018/19. It is assumed that the unidentified savings highlighted below will be delivered through the Dorset wide schemes. The key Dorset wide schemes that will improve the financial position of the Trust are working towards integrated community services and developing Accountable Care Partnerships. Work programmes to take this work forward have been agreed through the Dorset Senior Leadership Team. In addition, the Trust is planning to continue to deliver its own Cost Improvement Programme: exploiting the opportunities highlighted by the Carter Review and the NHS Better Care, Better Value Indicators.


The following table summarises the planned savings for 2017/18 and 2018/19, and those forecast to be achieved in 2016/17.

CIP 2016/17 Forecast Saving - £m

2017/18 Planned CIP - £m

2018/19 Planned CIP - £m

Workforce Efficiencies 3.239 6.363 3.910

Non Pay 2.912 3.584 0.650

Income 0.549 0.355 0.700

Total 6.700 10.302 5.260

Split as

Identified 5.903 4.355 5.260

Unidentified 0.797 5.947 - In the operational plan for 2017/18 the CIP for the identified schemes has been phased across the four quarters on the basis of forecast delivery. The £5.947 million attributable to the unidentified system-wide schemes has been phased in the final quarter of the year, as plans for these have not been confirmed. This gives the maximum period for the plans to be confirmed and the realisation of the savings to be achieved. It is anticipated that a further £750,000 of savings will be identified by the Trust in the next month, and detailed plans are currently being developed for these. The remainder of the plans will be developed across Dorset in the final quarter of the year. The identified schemes cover the following areas:

Workforce efficiencies (identified target 2017/18 £2.2 million) - further reductions to workforce costs are planned through collaborative changes in pathways through the Acute Vanguard project the Trust is part of and review of staffing levels across the Trust. The Trust will also focus on reducing spend on agency and locums, utilising the NHS Improvement cap rates, as well as managing vacancies more effectively and consistently.

Non pay (identified target 2017/18 £1.6 million) – procurement savings through involving clinical input to standardise the range of products used, and driving savings through robust price negotiation and contract management using NHS purchasing power and the opportunities highlighted in the Carter review. Further savings are planned through review of IT and maintenance contracts.

Drugs (identified target 2017/18 £0.3 million) - savings are planned on drugs expenditure through schemes including switching to bio-similar drugs, reviews of usage and taking advantage of those coming off patent. Revenue generation (identified target 2017/18 £0.3 million) - additional income is expected to be generated through commercial schemes including an increased offering of private healthcare.

4.8 Lord Carter’s Provider Operational Productivity Work Programme

The Trust has developed an action plan to take forward recommendations of the Carter Review. The Better Value Better Care Board is overseeing the implementation of the plan, the key actions of which are shown in the table below.


Carter Priority Action Clinical Efficiencies

Workforce resourcing group focussing on rostering efficiencies and a specific project has been set up to improve the efficiency of nurse rostering.

Pharmacy Pharmacy Transformation Plan approved. Early action to reduce medicine stock levels.

Diagnostics Strategic Outline Case agreed for Pathology Services Procurement Procurement Strategy and Transformation Plan approved. Estates and Facilities

Key opportunities arise in reducing energy costs and a case is being prepared to implement a cost effective Combined Heat Plant and a review of water usage has been commissioned. Further work needs to take place to reduce our waste costs.

Corporate & Admin Costs

A case for change has been prepared for Business Support Services moving towards a shared service approach through the Vanguard Project. A case for implementing digital solutions is being prepared.

Get it Right First Time

There is currently a focus on Urology services following a Carter Review Visit.

Digital Information Systems

The Digital Patient Record project is progressing.

4.9 Agency Rules

The Trust has developed a comprehensive plan to help manage and reduce the use of agency staff. The details of the plan are included in the Workforce section of this narrative above.

The Trust is working with neighbouring Trusts to appoint framework solutions and providers, with the intention of implementing an agency framework by 31 December 2016, to enable the appointed Tier 1 and Tier 2 suppliers to ‘go live’ by 31 January 2017.

In addition the Trust is planning to implement the following by 31 January 2017: mandating the use of direct engagement for all medical and AHP bookings; contractual terms that ensure a reduction in agency margins where pay rates exceed the NHSI cap; the establishment of weekly and monthly management information for all key stakeholders; and monthly service reviews with Tier 1 providers moving to quarterly when established.

4.10 Procurement

The Trust recognises that tightly controlled procurement practices can contribute substantially to efficiency and the successful delivery of its plan. Therefore, during 2016/17 the Trust has developed a new Procurement Strategy, taking into account an external review of its non-pay expenditure, feedback from internal stakeholders and experience of other trusts across the country. The Strategy has been approved by the Trust Board and is supported by a Procurement Transformation Plan, which sets out the steps necessary to enable the Trust to achieve


Level 2 of the NHS Standards of Procurement by September 2018, and to meet the Procurement targets set out in the Carter Review. The Trust is engaging with the programme to develop the Purchase Price Index Benchmarking tool.

4.11 Capital Planning

The Capital Programme for 2017/18 and 2018/19 has been produced using a risk based approach, using likelihood and consequence, with the very high risk and high risk scored items being the priorities. The Trust has continued to use the additional capex criteria framework included in the 2016/17 Operational Plan to assess capital schemes using project need and project urgency as further criteria.

The main priority for the 2017/18 Capital Programme is the continuation of the Integrated Digital Care Project (IDCR). The Trust secured £950,000 of funding from the NHS England Integrated Digital Care fund in 2015/16 towards the cost of the IDCR. The project’s objective is to ‘achieve paper-light, streamlined clinical processes, enabled by the provision of a single, integrated digital care record for each patient, available at the point of care to support clinicians in delivering better patient care’. The existing Catheter Lab has reached the end of its useful life. The existing equipment regularly fails putting the lab out of action, which adversely affects patient care. This was a key scheme for 2016/17, but delays to the work as a result of the need to upgrade the ventilation and air flow in the lab room, has meant that the equipment will now be delivered in early 2017/18. With the replacement of this equipment, and the benefit of more advanced technology, patients will have a much better experience. The Trust’s MRI Scanner was purchased under a finance lease, which expires in October 2017. The Scanner is in good condition and the Trust will look to extend this lease for a further three years. This will provide much better value for money and is more affordable than either purchasing a new MRI Scanner outright or taking out a new lease. Within the Estates Schemes some core infrastructure is required to be replaced in 2017/18. The Trust is currently working with the Carbon Energy Fund (CEF) to look at alternative ways of securing these assets.

The Capital Programme for 2017/18 includes schemes which have slipped from 2016/17, which is why the Capital Programme overall total of £6.156m is greater than depreciation of £5.470m. These schemes, including the Catheter lab equipment above, were slipped back to 2017/18 where there was uncertainty if they would be completed by the end of Q4 2016/17.

The Trust, in line with relevant accounting standards, undertakes a review of asset lives and an impairment review on an annual basis. During 2016/17 the Trust has engaged with a Chartered Surveyor to review the lives and valuation of its land and buildings, which resulted in the asset lives being extended. The Trust also has a space Utilisation Group which meets on a regular basis to consider the use of space within the Hospital and looks to optimise the best use of this space. The Trust has managed equipment services in Pathology and took out a new managed service for Print Management, which saw an improvement in the technology and service provided. Going forward, the Trust will be considering further managed services and leasing alongside the more traditional approach of purchasing assets outright.


5. Delivering ‘Our Dorset’ Sustainability and Transformation Plan

During 2016/17, health and social care partners across Dorset came together to develop ‘Our Dorset’ STP, which sets out a clear vision: we want to provide services which meet the needs of local people and deliver better outcomes. To deliver our vision we have three interconnected programmes of work to drive forward changes to our services in order that we meet the differing health and care needs of local children and adults, as illustrated below.

Our three programmes of:

1. Prevention at Scale- will help people to say health and avoid getting ill;

2. Integrated Community Services- will support individuals who are unwell, by providing high quality care at home and in community settings;

3. One Acute Network- will help those who need the most specialist health and care support, through a single acute care system across the whole of Dorset.

These programmes are supported by two enabling workstreams of:

Leading and Working Differently- which focusses on giving the health and care workforce the skill and expertise need to deliver new models of care in an integrated health and care system;

Digitally Enabled Dorset- which will increase the use of technology to support new approaches to service delivery.

Delivery of our STP will be overseen through the System Leadership Team, with each organisation individually and collectively accountable. The following section of our operational plan sets out the priority for each of our workstreams over the next two years.

5.1 DCH Strategy Our strategy, key priorities and critical transformation programmes for Dorset County Hospital have been developed in alignment with the five main workstreams of the STP - and these workstreams provide the portfolio framework for our sustainability and transformation initiatives. The outputs and outcomes of the STP workstreams, aligned to our organisational strategy and priorities, are crucial to delivering long-term sustainability. In combination, we anticipate a reduction in demand and more efficient delivery of services which will contribute to closing the ‘three gaps’ at a system level and meeting our operational and financial challenges.


We have developed the following strategic objectives and key priorities which will help us achieve our vision of delivering compassionate safe and effective health care and outstanding care for patients in ways which matter to them and focus on our mission of playing a leading role in collaboration with our partners in the development of an integrated, patient centred health and care system. The Chair and Chief Executive of DCH have presented this strategy to, and sought feedback from, partner provider Boards across Dorset.

The Board of Directors at DCH have considered and reviewed the critical transformation programmes based on an assessment of the quality, access, patient experience, staff experience and financial impact and agreed that these are:

Critical Transformation Programmes for DCH

Purpose

Access and Quality Programme Focussed on ensuring internal processes and pathways are centred around the patient so that quality and effective services are provided to patients.

Integrated Community Services /Accountable Care Partnership

To work with partners and integrate and join up patient services and pathways across the system and reduce demand into the hospital and reduce those delayed and stranded

Mid-Dorset Integrated Health-care Hub

To develop an integrated health care hub for the mid-Dorset population and beyond which reduces demand for acute, in-hospital services and enables quicker discharge

Acute Care Collaborative Vanguard

To develop joined up services with our acute partners in Poole and Bournemouth to reduce variation and supply-side costs

Business Support Shared Services Working with health partners across Dorset to share services in a way which maintains or improves quality and reduces supply-side costs

Digital Patient Record Developing an integrated patient record which interfaces with partners and the Dorset Care Record

Damers To review the use of our footprint and develop solutions which alleviate strategic and operational challenges and generate income

Commercial programme To increase income from non NHS sources, such as private patients and the use of

other assets

Cost Improvement Programme To ensure all services are as efficient as possible. Including Sustainable Services, Carter and GIRFT


The critical transformation programmes for DCH align to the STP workstreams as set out below:

STP Workstream DCH Critical Programmes aligned to STP workstream Prevention at Scale Accountable Care Partnership One Acute Network Acute Care Collaborative Vanguard Programme with Poole Hospital and

Royal Bournemouth and Christchurch Business Support Shared Services Access and Quality Programme CIP, Commercial and Damers

Integrated Community Services

ICS Mid-Dorset Integrated Hub

Digitally Enabled Dorset Digital Patient Record

Leading and Working Differently

ACP Business Support Services

5.2 Alignment with CSR and STP Planning Assumptions Programme approach to system wide demand management The first two years of STP planning is aimed at reducing demand and reversing historical growth seen in Dorset, this will allow organisations to free up capacity and reduce costs to enable transformational changes in years 3-5 as identified in the STP and as part of the Dorset CSR. In order for the system to deliver at scale on the financial challenge and to support delivery of a reduction in the current growth of activity (flat activity), the Finance Reference Group (Directors of Finance across the system) have identified a number of ‘quick wins’ which will be taken forward over the next 3 months these will include: referral management- focussing on doing things differently such as implementation of

best practice, in house second opinion, educational interventions and structured education; productivity improvement and one Dorset approach to referral process;

primary care demand management (part of right care)- focussing on reducing variations, peer review of referrals, triage of specialities;

low priority procedures- review and endorsement of limited clinical value procedures process;

RightCare and realistic medicine- dermatology. ENT, neurology, oral surgery, ophthalmology, orthopaedics, urology and integrated teams (in addition to those in the table overleaf);

‘Getting it Right First Time’ programme.

We expect the programmes outlined above to be the start of delivering changes that will reduce activity in hospitals and move the system towards the strategy outlined in the STP for greater care outside of hospital delivered in a more integrated way with social care. Senior Responsible Officers have been identified for these programmes and for the first time system-wide groups of medical, operational and finance executives will be leading on delivering the plans.

Finally, modelling for the CSR/STP has been undertaken on a macro level as opposed to on a meso or micro level and therefore at this stage high-level outcomes cannot be assumed to translate to locality specific service delivery.


6. Membership and elections

Dorset County Hospital has a membership of approximately 3020 public and 3366 staff and a Council of Governors comprising 16 Elected Public Members, 4 Elected Staff Members and 8 Appointed Members.

During 2016/17 there were no governor elections. The Trust will be commencing Governor elections to conclude in May 2017 The Trust allows Governors to attend as observers at a range of committee meetings giving them the opportunity to both observe the meeting but also contribute at the end of the meeting where their questions and/or comments are welcomed. The Trust also runs quarterly Governors’ Working Groups and Governors attend the South West Governor Exchange Network. Each year the Trust runs a range of events aimed at facilitating engagement between governors, members and the public, and to provide a greater insight into the work of the Trust. Events during 2016/17 comprised:

Members’ Events in July and November 16 and planned for March 2017 Trust Open Day October 16 AGM and AMM September 16

The Trust plans to hold the following engagement events during 2017/18:

Four Members’ Events Trust Open Day October 17 AGM and AMM September 17

In addition all Council of Governors meetings are open to members (4 per annum) and the Trust produces two newsletters and two e-bulletins per annum. The Trust has a Membership Development Strategy covering the period 2012/13 – 2016/17. The Trust will review its Membership Development Strategy during 2017. The membership leaflet was revised in December 2014, to make the benefits of membership clearer and to make the leaflet more visually appealing. Minor amendments to the new style leaflet were made in April 2015 and a frequently asked questions factsheet was added in February 2016. Membership pages of the Trust website were revised when the Trust launched its new website in January 2015. Membership pages are updated regularly with the latest events, election news and newsletters. The Trust has a Membership Development Committee which meets quarterly and is looking at increasing opportunities for face-to-face recruitment and the use social media to promote events.

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