BOARD OF DIRECTORS Wednesday 1 September 2021 at 09:30-10:15 MS Teams/Boardroom, Yeovil District Hospital NHS Foundation Trust AGENDA - PART 1 Action Presenter Time Enclosure
1 Welcome and Apologies for Absence Chairman 09:30 Verbal
2 Register of Declarations of Interest and to Confirm Receive and All Appendix 1 Declarations Relating to Items on the Agenda Note
3 Minutes of the Meetings held on 4 August 2021 Approve Chairman 09:35 Appendix 2 and to Discuss Matters/Actions Arising
4 YDH Group Board Overview Quadrant Receive and Shelagh Meldrum 09:40 Appendix 3 (Inc. updates on Finance, Quality, Performance, Workforce Note Matthew Bryant for YDH and Subsidiary Companies) Stacy Barron- Fitzsimons Sarah James
5 Strategic Case for Merger with Somerset NHS Note Chairman / 09:50 Appendix 4 Foundation Trust Jonathan Higman / Jeremy Martin
6 Any Other Business and Meeting Close Chairman 10:15 Verbal
7 Date of Next Public Meeting 6 October 2021 via MS Teams in the Boardroom, Level 1, Yeovil Hospital
Board of Directors – Declarations of Interest August 2021 the following table sets out the declaration of interests of the Board of Directors (voting and non-voting).
Name Position Interests Declared Chairman and Non-Executive Directors (Voting) Paul von der Heyde Chairman -Trustee and Adviser Howlands Furniture Group, Office Furniture Manufacturer -Sister-in-law is the sister of Dr Ali Parsa who is the Founder and Chief Executive Officer of Babylon Healthcare Services -Chairman and Director of The Worshipful Company of Furniture Makers’ Charitable Funds incorporating the Furnishing Trades Benevolent Association -Director and Shareholder of Herswell Coaching and Consulting Limited -Chairman of Psoriasis and Psoriatic Arthritis Alliance & PAPAA Enterprises Ltd -Director and Shareholder of Sweetfish Limited -Chairman of Axminster Tool Centre Limited Jane Henderson Non-Executive Director -Private Practice Therapeutic Counsellor -Part-time, self-employed counsellor for Frome Birth Talk Martyn Scrivens Non-Executive Director -Chairman of Simply Serve Limited -Non Executive Director and Chairman for Retail Money Market Limited (trading as RateSetter and a 100% subsidiary of Metro Bank Plc) -Director of Tanyard Consulting Limited -Non Executive Director and Chair of Audit Committee of Hampshire Trust Bank Limited Graham Hughes Non-Executive Director -Volunteer Advisor at Citizens Advice -Parish Councillor of Babcary Parish Council -Chairman and Trustee Director of Avon Mutual Paul Mapson Non-Executive Director -No declarations Executive Directors (Voting) Jonathan Higman Chief Executive -Director, Symphony Healthcare Services Limited -Director, Yeovil Property Operating Company Limited -Director, YEP Project Co. Limited -Management Board Member, Yeovil Strategic Estates Partner Board Shelagh Meldrum Deputy Chief Executive/Chief -Non-Executive Director, Simply Serve Limited Nurse & Director of People -Husband is employed as the Head of Contracting & Business Performance Lead at Yeovil District Hospital Sarah James Chief Finance Officer -Branch Treasurer for South West Branch of Healthcare Financial Management Association -Trustee of RICE (Research Institute for the Care of Older People) -Director, Symphony Healthcare Services Limited -Non-Executive Director, Simply Serve Limited -Management Board Member, Yeovil Strategic Estates Partner Board -Director, YEP Project Co. Limited -Member of Southwest Pathology Services Board (Joint Venture) Merry Kane Chief Medical Officer -Shareholder/Director of Jobson Medical Services Limited -Husband works for Jobson Medical Services Limited which holds contracts with CARE UK -Husband is a consultant at Musgrove Park Hospital Executive Directors (Non-Voting) Matthew Bryant Chief Operating Officer -Chief Operating Officer (Hospital Services) at Somerset NHS Foundation Trust -Trustee for Hospiscare, Exeter -Visiting Specialist, Plymouth University Peninsula Medical School Stacy Barron- Director of Operations -Husband is employed as Cyber Security Manager at Yeovil Fitzsimons District Hospital NHS Foundation Trust Jeremy Martin Director of Transformation -Trustee, Spark Somerset
Paul Foster Deputy Chief Medical Officer -Wife is a GP Partner for The Grove Medical Centre Non-Executive Directors Observers (Non-Voting) Barbara Clift Non-Executive Director -Non-Executive Director, Somerset NHS Foundation Trust Observer -Trustee of SWEDA -Daughter’s partner is CIO of KPMG Stephen Harrison Non-Executive Director -Non-Executive Director, Somerset NHS Foundation Trust Observer -Chair, YMCA Mendip -Trustee, Lawrence Centre, Wells -Governor, Wookey Primary School
APPENDIX 2
BOARD OF DIRECTORS DRAFT Minutes of the Part 1 Board of Directors Meeting held on Wednesday 4 August 2021 via MS Teams at Yeovil District Hospital
Present: Paul von der Heyde Chairman Jane Henderson Non-Executive Director Graham Hughes Non-Executive Director Paul Mapson Non-Executive Director Martyn Scrivens Non-Executive Director Shelagh Meldrum Deputy Chief Executive/Chief Nurse & Director of People Sarah James Chief Finance Officer In Attendance: Stacy Barron-Fitzsimons Director of Operations Jeremy Martin Director of Transformation Paul Foster Deputy Chief Medical Officer Samantha Hann Corporate Governance & Risk Manager Ben Edgar-Attwell Associate Director of Integration [items 5 & 6] Michael Beales Public Governor Peter Lewis Somerset NHS FT Chief Executive Barbara Clift Somerset NHS FT Non-Executive Director Apologies: Jonathan Higman Chief Executive Merry Kane Chief Medical Officer Matthew Bryant Chief Operating Officer Stephen Harrison Somerset NHS FT Non-Executive Director
Ref: No: Action 1-38/ 1 WELCOME AND APOLOGIES FOR ABSENCE 2122 1.1 Paul von der Heyde welcomed everyone to the meeting and in particular Peter Lewis, Somerset Foundation Trust (SFT) Chief Executive and Michael Beales, Public Governor. Apologies were received as noted above.
1-39/ 2 DECLARATIONS OF INTEREST 2122 2.1 The register containing the declarations of interests from members (voting and non-voting) of the Board was noted. Shelagh Meldrum asked the Board to note the change in her husband’s role within YDH. She advised the declarations of SM interest register will be updated to reflect this change.
1-40/ 3 MINUTES/ACTIONS OF THE PREVIOUS MEETING 2122 3.1 The minutes of the meetings held on 7 July 2021 were approved as a true and accurate record.
3.2 With regard to actions and matters arising, Paul von der Heyde advised action 1- 5/2122 (5.3) in relation to risk appetite has been started and will be actioned within the Joint Board to Board meetings but this action is not yet completed.
1-41/ 4 EXECUTIVE DIRECTOR REPORT 2122 4.1 Shelagh Meldrum highlighted the challenging operational position the Trust was currently experiencing with increased prevalence of Covid-19 in the South Somerset area; an increase in staff absence; the challenge with demand in the Emergency Department; and the issues with being able to discharge patients.
4.2 Shelagh Meldrum advised despite many restrictions being lifted nationally on the 19 July 2021, restrictions remain in place in the hospital. She said visiting had been further restricted which has been challenging to manage the paradox for the public of restrictions easing nationally but tighter within the hospital.
4.3 Shelagh Meldrum advised the development session for the Board later that day will focus on the operational pressures where the Board will discuss the challenges in more detail. She advised the teams are managing exceptionally well and support has been received by the system.
4.4 Shelagh Meldrum spoke of the iCARE week in July focused on Infection Prevention and Control which was set against the back drop of the national restrictions lifting.
1-42/ 5 BOARD ASSURANCE REPORTS 2122 Infection Prevention Control (IPC) Board Assurance Framework (BAF) 5.1 Shelagh Meldrum confirmed the IPC BAF is presented each quarter to the Board with changes each quarter shown in highlighted text. She advised changes within the quarter include intensive environment risk assessments which are focused on prevalence with decisions being made locally; an increased focus on ventilation; the new cleaning standards; social distancing measures; and a change in the use of FFP3 masks.
5.2 In relation to ventilation, Shelagh Meldrum spoke of the window replacement programme throughout the tower block and advised this was currently on hold due to operational pressures and beds unable to be closed to facilitate this programme of work. She confirmed window ventilation blocks are in place.
5.3 Shelagh Meldrum advised the new cleaning standards are new hospital standards and are not Covid-19 related. She advised that the team are working hard on implementing the new standards and the Trust aims to implement the new standards by October 2021 which is earlier than the national implementation date. Shelagh Meldrum confirmed star ratings will be displayed across the hospital. It was agreed Brendon Woods would be invited to a future SH Board meeting to provide an overview of the new standards.
5.4 An overview of the changes in the FFP3 mask guidance was provided to the Board by Shelagh Meldrum advising previously the use had been for high risk procedures only, but this has now changed to risk assessments being made at a local level dependant on the risks identified. She confirmed that the Trust are rolling this out across all areas of the hospital and testing staff.
5.5 Shelagh Meldrum confirmed that the Gold Command role remains in place 7 days a week undertaken by the Directors and the Deputy Directors. She advised IPC walk arounds are in undertaken by the Gold Command and the IPC team to ensure standards are being met. Shelagh Meldrum said that all patients that are clinically vulnerable who are unable to be cared for in side rooms are incident reported.
5.6 Graham Hughes said historically turnover within housekeeping staff can be high and he asked whether SSL is able to recruit the level of staff required. Shelagh Meldrum advised currently there is more pressure on the team due to sickness and absence. This has led to the team having to reduce cleaning in some non- clinical areas on occasion when the team is extremely challenged. She advised there is some challenge with recruitment as with domiciliary care and healthcare assistants especially with the hospitality sector offering better rates of pay and bonuses.
5.7 Paul von der Heyde questioned the current level of sickness absence due to Covid-19 to which Shelagh Meldrum advised there are currently 45 members of 2 | P a g e
staff either off with Covid-19 or isolating. The difficulties in identifying where staff contract Covid-19 from was discussed but it was agreed that with the IPC measures in place whilst staff are at work this reduces the risk significantly.
Q1 Board Assurance Framework (BAF), Q1 Board Corporate Risk Register & Q1 Risk Assurance Committee Report 5.8 Paul von der Heyde confirmed the Board Assurance Committees have reviewed both reports in detail.
5.9 Shelagh Meldrum highlighted to the Board the top five risks to the organisation. She advised the Board that Risk 198 ‘staff resilience’ has increased within Q2. She advised the risks in relation to Cancer Services were discussed within Governance and Quality Assurance Committee (GQAC).
5.10 Paul von der Heyde asked the Chairs of the Board Assurance Committees for anything they wished to raise to the Board. Jane Henderson advised as demonstrated within the Corporate Risk Register, a number of risks are now increasing and the numbers of risks on the Corporate Risk Register are increasing each quarter. She summarised the decision that took place within GQAC regarding the Oncology Service. Jane Henderson spoke of the risk of harm to patients with longer delays, demands on services, staff pressures within services and taking into account the staff resilience risk. She advised in relation to SR1 on the BAF, it had been reflected in GQAC that this risk has also increased within Q2.
5.11 Graham Hughes advised that the Workforce Committee had been postponed until 12 August and the risks within the remit of the Committee would be discussed in detail.
5.12 Paul Mapson spoke of the discussion that took place at the Financial Resilience and Commercial Committee regarding reframing the financial risks in light of the financial arrangements for the second half of the financial year. Sarah James confirmed the financial risks both on the risk register and the BAF will be reviewed in September.
5.13 Paul von der Heyde noted that the Board needs to review the risk appetite for the organisation and have a greater understanding of the risks that are currently being tolerated. He reflected that the Joint Board to Board meeting had a discussion on risk tolerance and risk appetite and noted the work that was underway to review the approach by both organisations. Peter Lewis echoed Paul von der Heyde comments and welcomed a future review of the risk appetite and risk tolerance.
5.14 Michael Beales questioned whether the pressures on the Oncology Service would be positively impacted by bringing the services back on site at the hospital rather than being held off site. Stacy Barron-Fitzsimons advised the service was moved off site at the start of the pandemic to protect the most vulnerable patients. The feedback received has been extremely positive. She confirmed the teams are continuously reviewing how the YDH estate is used and at present there is no immediate plans to change where the Oncology service is sited. Shelagh Meldrum reflected it does impact on the flexibility of the staff being off site as they are unable to view their patients if they are inpatients on the wards on the main hospital site but balancing this risk with the risk of being on site especially with prevalence rising, it is safer for the Trust’s most vulnerable patients to be seen off site.
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5.15 Shelagh Meldrum spoke of the Risk Assurance Committee meetings held within the quarter and provided an overview of the role of the Committee. She provided a summary of the topics reviewed within the quarter including End of Life Care, Fire Safety and Health and Safety management and when asked by Paul von der Heyde whether progress was being made in relation to those topics which felt directly under the remit of the Board, Shelagh Meldrum provided an overview of the good progress being made.
Q1 Learning from Deaths Report 5.16 Paul Foster advised the GQAC in the meeting held in July received a presentation from Tim Scull, Medical Examiner, on the Medical Examiners service. He spoke of the shift from reviewing the data and statistics to reviewing the learning and the relationships with the bereaved families and the difference this is making.
5.17 In relation to the Q1 report, Paul Foster provided the Board with the highlights from the report including; the reassuring HSMR data which reflects the good standards of care the Trust provides; the increase in ensuring comorbidities are coded correctly; and the increase in low risk deaths which is in line with national figures.
5.18 Paul Foster spoke of the improvement in documentation from the mortality reviews that have been undertaken. He highlighted the improvement that was required in relation to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) and Treatment Escalation Plans (TEP) as reflected on the risk register.
5.19 Jane Henderson provided a summary of the presentation received in relation to the Medical Examiners service which included; the context of the service; the volume of cases that have been reviewed including which types of cases are not eligible as there are other services in place that review these deaths; an overview of the role of the Medical Examiner and the importance of their independence; the future plans for the service including the extension to deaths outside of the hospital – community and general practice deaths; and trends and themes.
5.20 Shelagh Meldrum highlighted the concern raised by Tim Scull regarding the resource required when the service is expanded beyond hospital deaths. She advised Tim Scull had described to GQAC the complexities for the Medical Examiners in reviewing deaths in the community in relation to access to medical records and staff. Shelagh Meldrum advised she had agreed with Tim Scull that there is an urgent need to understand the additional resource requirements and the expectation on Trusts to deliver this element of the service.
5.21 Paul Foster said the Trust currently has a 5 day Medical Examiner service providing one session per day so to add community deaths will need a significant increase in resource and due to the criteria of who is able to become a Medical Examiner, this additional resource will be taken from a small pool of senior medical staff.
5.22 Graham Hughes echoed the concerns raised regarding the risk of resource when the service is expanded. He also advised the Board that Tim Scull is due to retire in September 2021 and his role needed to be recruited to. Paul Foster said an advert is currently out for Tim Scull’s replacement.
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Q1 Freedom to Speak up Guardian Report (F2SU) 5.23 Shelagh Meldrum said there had been no reports F2SU reports during Q1. One had remained open but this has since been closed within Q2. She advised Emma Symonds, Equality, Diversity & Inclusion Lead, has recently been appointed as the fourth F2SU Guardian.
5.24 Shelagh Meldrum advised meetings with the F2SU Guardians at SFT are underway with the Guardians currently reviewing the ways of working and what are reported at both Trusts. It has been identified that SFT record the pastoral support they provide to staff which YDH do not currently record.
5.25 Peter Lewis advised there is a significant number of reports raised at SFT compared to YDH. He supported the work of the two teams reviewing current practices and spoke of the engagement work he is aware both Trusts undertake with staff.
5.26 Jane Henderson advised Fiona Rooke, F2SU Guardian, had reported to QGAC there is a different threshold for reporting at both Trusts and the teams are currently reviewing this and comparing what the comparison data would demonstrate if YDH reported their pastoral support as well.
5.27 Shelagh Meldrum advised that all staff when they speak to the Guardians are asked if they wish to raise their concern/comments through the F2SU route but most staff do not wish this to happen, they are satisfied with the discussion with the F2SU Guardians. She advised the work Emma Symonds undertakes with the staff networks will help to identify any themes and triangulate the data.
Q1 Guardian of Safeworking Report (GoSW) 5.28 Paul Foster provided a summary of the report compiled by Andrew Newton, ED Consultant and Guardian of Safeworking. He highlighted concerns are equal to pre-Covid-19 levels in relation to working additional hours and a decrease in support. He noted there had been no fines within Q1 and the concerns raised regarding breaks for staff within Emergency Department (ED) at weekends was immediately addressed.
5.29 Paul Foster advised the specialties of concern are ED, Medicine and Surgery. He said sickness within the surgical workforce is a concern and is being reviewed. The pressures in ED are being addressed with support from the specialty teams.
5.30 Paul Foster highlighted to the Board that the Guardian of Safeworking only covers Junior Doctors and there is currently no reporting system nationally that covers Senior Doctors. He advised the Board the Trust had previously had a Senior Doctor Staff Committee which was a forum for senior doctors to share their concerns and issues without the presence of the Clinical Directors. Attendance continued to decrease and there were difficulties in finding a Chair so the Committee was disbanded. Paul Foster advised that the Committee is now to be relaunched to provide senior staff with a forum to report concerns in addition to raising directly with Merry Kane, Paul Foster, Associate Medical Directors and/or Clinical Directors, but finding a Chair remains difficult.
5.31 The Board discussed the new intake of junior doctors and the challenge they will face starting at such a difficult time for the NHS. Shelagh Meldrum reflected the support for the junior doctors on the wards to help support their induction to the Trust.
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1-43/ 6 YDH GROUP BOARD OVERVIEW QUADRANT 2122 6.1 The Board reviewed the YDH group overview quadrant. The following was discussed in more detail:
6.2 In relation to patient experience, Shelagh Meldrum advised patient falls and VTE risk assessments had been reviewed within the Governance and Quality Assurance Committee on 27 July 2021. The Committee had been advised that falls are returning to pre Covid-19 levels but a potential theme is emerging where patients are cohorted due to Infection Prevention and Control (IPC) requirements and this is currently being reviewed by the Falls Team.
6.3 Shelagh Meldrum advised the Tissue Viability team are under a significant amount of pressure as this is a small team who have shared leadership with the Infection Prevention and Control team and staff members on long term absence. Patients are coming in from the community with complex wounds and pressure damage. The team are actively trying to recruit into a secondment post to provide support.
6.4 Shelagh Meldrum noted that there was one never event included within the quadrant but she confirmed to the Board this was discussed last month and this is not an additional never event for the Trust.
6.5 It was noted that complaints and PALS concerns remain static and at a low level for the Trust. Shelagh Meldrum advised the Board that complaints are now starting to be received which relate to the beginning of the pandemic which are complex to manage. There is also an increasing public perception that the pandemic is over and the hospitals are not under any pressure. Shelagh Meldrum spoke of the work the Trust are doing to ensure perceptions and the expectations on the hospital from the public are well managed.
6.6 Shelagh Meldrum advised Friends and Family was an agenda item which would be covered later in the meeting. She confirmed readmission rates are being closely monitored.
6.7 In relation to safe staffing, Shelagh Meldrum advised the fill rate is currently at 80% which is not ideal given the escalation areas in use currently and the additional staffing required for these areas. It was noted by the Board that the sickness absence rates mainly refer to clinical staff now. This is thought to be due to non-clinical staff having the ability to work from home now and therefore they are not reporting their absence as they are making a decision to continue to work from home.
6.8 Paul von der Heyde questioned the cases of Cdiff within the quarter and asked if these were hospital acquired. Shelagh Meldrum advised there had been a requirement to change the reporting and non-hospital acquired cases are now to be reported and the Trust reviews whether there has been lapses in care. She confirmed the Trust work with the community teams across the County.
6.9 Stacy Barron-Fitzsimons advised the Trust is currently below the national standard of 95% for the 4 hour A&E wait performance. She did however reflect that YDH still remains one of the best performing Trusts within the South West. In relation to Ambulance handover time, Stacy Barron-Fitzsimons advised performance is currently lower than the Trust would expect. Operational pressures the Trust were currently experiencing was noted it would be covered within the Board Seminar session later that day.
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6.10 The Board were advised the Trust is currently achieving 70% for RTT performance which is an improvement with the teams working hard to achieve this. Stacy Barron-Fitzsimons advised the worse performing specialities are Ear, Nose & Throat (ENT) and Neurology. She advised these are visiting specialities and the Trust is working with System partners to develop a sustainable service. Stacy Barron-Fitzsimons confirmed the risk associated with RTT performance is reflected on the Corporate Risk Register and clinical harm reviews are undertaken before harm arises to help manage and prioritise the patient backlog.
6.11 Stacy Barron-Fitzsimons advised there has been a 4% deterioration in diagnostic wait times due to MRI. She advised the Radiology team have seen a 13% increase in demand which is continuing to grow.
6.12 In relation to Cancer Services data for May 2021, Stacy Barron-Fitzsimons advised the Trust almost achieved the 93% two week wait standard. She advised the Trust is slightly below the national standard for the 62 day standard due to diagnostic and tertiary delays. The Team are working hard to try and recover performance but this remains a challenge.
6.13 Jane Henderson thanked Stacy Barron-Fitzsimons for the assurance regarding diagnostic and cancer services and questioned the direction for these services over the next few months. Stacy Barron-Fitzsimons advised the teams are taking mitigating actions but due to the current pressures and demands, there will be a decline in the position particularly for RTT and diagnostics with routine patients waiting longer to be seen. She noted that YDH is still performing well within the South West but not against the internal performance standards the Trust sets itself.
6.14 Stacy Barron-Fitzsimons advised the cancer performance will also decline with a high number of breaches within June and July which have been beyond the control of the Trust. The teams are working with SFT and the Cancer Alliance to manage this for the Somerset population. It was noted a decline in two week wait performance will have a knock on impact on the Trusts ability to deliver the 62 day standard.
6.15 Stacy Barron-Fitzsimons advised the Trust are at 100% outpatient activity when compared to 2019/20 data. 22-25% of outpatient activity is delivered virtually and this is continuously reviewed to understand which services can expand their virtual appointments. It was noted however that virtual appointments are not applicable to all services the Trust delivers.
6.16 Shelagh Meldrum said in relation to workforce and people, absence rates are higher than normal. She advised mandatory training compliance is positive and virtual training is working well. Shelagh Meldrum spoke of the virtual training that has been introduced within the maternity unit which supports MDT training. It was noted however some training can only be delivered face to face.
6.17 In relation to appraisal rates, Shelagh Meldrum advised compliance is fair. She reflected that staff are trying to complete their appraisals but this is difficult given the current operational pressures. Shelagh Meldrum said that some staff are finding it difficult to demonstrate compliance with their objectives when many of these were set before the pandemic. Another challenge is managers are completing the appraisals but finding the time to upload the appraisal onto the system can be a challenge. The Board were advised time is spent within the appraisals now discussing health and wellbeing with staff, opportunities for flexible working and looking at their aspirations for the future.
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6.18 Sarah James confirmed the financial slides were discussed within the Financial Resilience and Commercial Committee. She advised for Month 3, there is a £8,000 surplus and the Trust is £166,000 favourable to plan mainly due to the private patient income being greater than expected. She reflected that the costs of meeting the operational pressures seen in July will reduce the positive variance which will be demonstrated within the Month 4 report. Sarah James advised taking this into account, the Trust still forecasts a break even position for the first half of the year. In relation to costs associated with the pandemic and elective recovery delivery costs, additional income to cover these costs has been assumed within the positon in line with expected funding.
6.19 Sarah James advised there is a modest level of cost improvements within the April to September plan and the focus for the remainder of the year will be on ensuring the Trust is ready for the high level of delivery which is expected for the second half of the financial year. She advised Paul Meldrum has taken on an additional role and he will manage the coordination of business planning and CIP.
6.20 The inability to undertake some capital schemes due to operational pressures for instance the window replacement project; the challenges of the construction industry; and the continued impact of the pandemic were discussed. Assurance was provided there are clear plans in place to manage the capital programme including bringing forward other schemes where possible.
6.21 Paul Mapson advised a significant concern is that the financial arrangements for the second half of the financial year have not yet been announced. Sarah James agreed with Paul Mapson and advised the team are currently focusing on the information they are able to work on largely in relation to expenditure and reviewing against a set of assumptions in relation to income. Peter Lewis supported Sarah James in advising all the Trust can do at present is to make assumptions on what to expect and await the financial information. He reflected there is uncertainty for individuals Trusts, systems and nationally due to the second half of the financial year arrangements not yet being announced.
1-44/ 7 MATERNITY CNST SCHEME 2122 7.1 Shelagh Meldrum advised a detailed report setting out the basis on which the Board can be assured that the Trust has achieved the safety actions or for those which have not been achieved, there is a detailed action plan in place, was presented to the Board of Directors meeting held on 7 July 2021. The report included an outline of the process used to review the evidence and confirm compliance.
7.2 Shelagh Meldrum said that it had been agreed during the Board meeting on 7 July 2021 that the Board would receive a briefing paper electronically which would have been scrutinised by the Executive Directors during an informal Executive Director meeting on 13 July 2021 and formally noted within the Executive Committee on 20 July 2021.
7.3 Shelagh Meldrum confirmed a subsequent briefing paper was produced and circulated to the Board of Directors on 14 July 2021 clarifying the position with the CNST designation. The Executive Directors provided assurance to the Board of Directors that the Trust has met the requirements and recommended to the Board that the Chief Executive, with the permission from the Board of Directors, sign the declaration form.
7.4 Shelagh Meldrum confirmed that the Board of Directors accepted, via email, the content of the briefing report as adequate assurance of an evidential basis for 8 | P a g e
meeting the requirements of the scheme with action plans in place for the safety actions that the Trust is not currently compliant with.
7.5 The Board of Directors therefore gave permission for the Chief Executive to sign the declaration form and this was submitted to NHS Resolution on Wednesday 21 July 2021. Shelagh Meldrum confirmed a copy of the revised briefing paper which contains the statements of commitment made by the Board of Directors following their approval are included within the Board papers.
7.6 Shelagh Meldrum advised the Board had agreed to sign the declaration form that confirmed that the Trust had complied with achieving all ten maternity safety actions; that the Trust Board had given their permission to the Chief Executive to sign the Board declaration form prior to submission to NHS Resolution; the Board declaration form had been signed three times and dated by the Trust’s Chief Executive to confirm that: the Trust Board are satisfied that the evidence provided to demonstrate achievement of the ten maternity safety actions met the required safety actions’ sub-requirements as set out in the safety actions and technical guidance; the content of the Board declaration form has been discussed with the commissioner(s) of the Trust’s maternity services; there are no reports covering either 2020/21 or 2019/20 that relate to the provision of maternity services that may subsequently provide conflicting information to the declaration (e.g. CQC inspection report, Healthcare Safety Investigation Branch (HSIB) investigation reports etc). All such reports had to be brought to the Maternity Incentive Scheme (MIS) team’s attention before 22 July 2021.
7.7 The Board noted the decision was made electronically by each member of the Board of Directors and noted the submitted declaration form signed by the Chief Executive on behalf of the Board. The Board of Directors confirmed their commitment to facilitate local, in-person, fetal monitoring training when this is permitted (safety action 6a – fetal monitoring training) and facilitate training when this is permitted (safety action 8 – maternity emergency training and neonatal emergency training).
1-45/ 8 FRIENDS AND FAMILY REPORT 2122 8.1 Shelagh Meldrum advised the Board that the Friends and Family feedback had been stood down last year due to the pandemic but that the Trust had continued to collect what feedback they could. She said Friends and Family has now been stood back up but due to the current operational pressures, the Trust has set a reasonable target for feedback.
8.2 Shelagh Meldrum reflected that QR codes are now in place to collate the feedback, which due to the wide use of these within the last 15 months, the general public are more used to using these now which should help the Trust to receive feedback.
8.3 Shelagh Meldrum said that the current feedback levels are within the expected range. She advised there is a focus on ensuring teams across the Trust receive the positive feedback. The themes identified at present include noise at night with patients and staff having to raise their voices due to masks being worn and discharge times as often these are later in the day or at night due to bed pressures and operational demands. Shelagh Meldrum said the areas identified are being reviewed but they will be difficult to improve with the current infection prevention and control measures in place and due to the operational pressures on the Trust.
8.4 Shelagh Meldrum advised the Board that national surveys have also recommenced including the maternity; inpatients; emergency department; and 9 | P a g e
children and young people surveys. She reflected it will be interesting to see what questions are asked this year and she noted the results will be difficult to compare to previous surveys.
1-46/ 9 WELLBEING GUARDIAN REPORT 2122 9.1 Graham Hughes presented the first Wellbeing Guardian report to the Board. He advised due to the timing of the Workforce Committee meeting after the Board of Directors, the report would be reviewed in detail during the meeting being held on 12 August 2021.
9.2 Graham Hughes congratulated the HR and Health and Wellbeing Team for the numerous initiatives in place for staff. It was agreed that the report would be presented on a quarterly basis to the Workforce Committee and the Board of SH Directors and Tracy Jones would be invited to attend the next Board meeting to present the item alongside Graham Hughes as the Wellbeing Guardian.
9.3 Graham Hughes advised he had attended the South West Wellbeing Guardian meeting and there had been discussion regarding the role and whether this should be an Executive Director rather than a Non-Executive Director role. He said some Trusts have really embraced the role and it was a good forum to exchange good ideas.
9.4 Martyn Scrivens said he felt it was important the role is undertaken by a Non- Executive Director so that staff are aware how seriously the Non-Executive Directors consider this area and that action that is taken is appropriate.
9.5 Martyn Scrivens asked whether there are target timeframes attached to each of the actions listed within the report to which Shelagh Meldrum advised these are included within the full detailed action plan that is in place. She advised the team are currently reflecting on the actions and will include an assessment of the impact them actions have made within the action plan.
9.6 Martyn Scrivens asked how success will be measured. Shelagh Meldrum advised a number of measures are in place which include regular pulse surveys for staff; seeking feedback from different staff groups, teams, individuals; introducing drop in sessions with different members of staff; asking for suggestions from staff of other initiatives that they would find supportive. She advised staff would love to socialise more but it is recognised this is still discouraged at present and therefore it will be difficult for the Trust to satisfy the needs of their staff. The Board reflected that healthcare staff behave differently to others and there is a public perception which had a reputational risk attached if staff do act irresponsibly.
9.7 Matthew Bryant said there is a great deal being undertaken by the Trust, some of which are common sense measures and many not new measures for YDH. Shelagh Meldrum said this was true but these initiatives are more purposeful now and staff need these more than ever before. She reflected that the resilience of staff is being tested and cracks are appearing and staff must feel supported and know how to access support.
1-47/ 10 BOARD ASSURANCE COMMITTEE TERMS OF REFERENCE 2122 10.1 Samantha Hann advised the Audit Committee; Financial Resilience and Commercial Committee; and Governance and Quality Assurance Committee had reviewed the revised terms of reference during the Committee meetings within July 2021. Minor changes had been proposed to the terms of reference which had been detailed within the circulated papers.
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10.2 Samantha Hann advised due to the timing of the Workforce Committee, the draft terms of reference would be reviewed within the meeting which was due to be held on 12 August 2021. The draft terms of reference for the Workforce Committee would be presented to the next Board of Directors meeting. SH
10.3 The Board of Directors confirmed they had reviewed the draft terms of reference and approved each of these for the relevant Board Assurance Committees.
1-48/ 11 COMMITTEE UPDATES AND MINUTES 2122 Audit Committee 11.1 Paul Mapson advised the Audit Committee met for the quarterly meeting in April 2021 and had an additional meeting in June 2021 to review the annual accounts and annual report. He thanked the teams for the work that had been involved in producing the annual accounts and annual report. He advised there were no issues he wished to raise to the Board of Directors.
11.2 In relation to the most recent quarterly Audit Committee meeting held on 27 July 2021, Paul Mapson advised there were no significant issues raised. He advised the risk management reporting arrangements to the Board Assurance Committees are under review.
Governance and Quality Assurance Committee (GQAC) 11.3 Jane Henderson advised GQAC met on the 16 June 2021 to review five annual reports; End of Life; Patient Experience, Safeguarding Adults and Children/mental Capacity; Medical Devices; and Medicines Management. She advised a further three annual reports were reviewed within the meeting held on 27 July 2021; Infection Prevention and Control; Maternity Services; and Dementia Care. A summary of each of the annual reports received by the Committee was provided to the Board which included; the creation of a linked dementia staff on the wards to keep to support the patients with the dementia and the small dementia team; difficulties in managing dementia patients due to infection prevention control measures in place; increase in patients presenting with self-neglect or due to abuse including domestic abuse; increase in section 42 enquiries particularly for learning disability patients; and carers to be theme for the Patient Experience Team over the next year.
11.4 Shelagh Meldrum urged all Board members to read the annual reports reviewed by GQAC as they provide an outstanding picture of the work undertaken across the Trust by the teams and the challenges the teams have and continue to face. She advised staff feel listened to by the Committee and it is important that this reaches all members of the Board. Jane Henderson said the annual reports have been well written and provide an understanding of the work undertaken by the Teams.
11.5 Paul von der Heyde asked if executive summaries are included within the reports to which Shelagh Meldrum advised they are not included but GQAC receive additional presentation slides delivered by the leads which provide the executive summary information including what has gone well for the service; what has not gone so well; and their plans moving forward. It was agreed by the Board that the annual reports and presentation slides for the eight annual SH reports would be circulated to all Board members for their review.
11.6 Barbara Clift said the Safeguarding teams within YDH and SFT are working collaboratively together and both Trusts have seen an increase in domestic violence. Jane Henderson advised there has been an increase in domestic homicides as well as non-accidental injuries in babies and together with the self- 11 | P a g e
neglect, these are the negative outcomes from the pandemic that organisations were concerned about.
11.7 Martyn Scrivens asked for the Non-Executive Directors who do not regularly attend GQAC to be invited to the meetings where annual reports are reviewed. This was agreed by the Board and will be actioned next year when the next set SH of annual reports are presented to the Committee.
11.8 Sarah James noted the disparity between attendance at the Board Assurance Committees by the Board and the need to consider the balance to ensure the Board’s focus is fairly represented in each of the Committees.
Financial Resilience and Commercial Committee (FRCC) 11.9 Martyn Scrivens advised the Committee reviewed the current financial position of the Trust and the national cost collection for 2019/20. In relation to the national cost collection, Sarah James noted the external audit of the quality of the cost collection work had been very positive with substantial assurance provided by the independent external auditors. She advised there were a couple low level recommendations which have largely been completed already.
11.10 Martyn Scrivens advised Sarah James had confirmed the financial risks both within the BAF and on the risk register would be reviewed in light of the risks the second half of the financial year present the Trust with and this would be reported back through the Committee in October during the quarterly reports. In relation to the review of the BAF and the Corporate Risk Register report, the Committee agreed to undertake a review of the financial risks sitting underneath the Corporate Risk Register threshold as a one off review.
1-49/ 12 ANY OTHER BUSINESS 2122 12.1 No other items of business were raised.
1-50/ 13 DATE OF NEXT MEETING 2122 13.1 6 October 2021, MS Teams/Boardroom, Level 1, YDH
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APPENDIX 2b BOARD OF DIRECTORS
BOARD OF DIRECTORS – ACTION SHEET 1 September 2021
Minute Action Progress Due By ACTIONS FROM 25 NOVEMBER 2020 1-82/2021 Using guidance, review individual recorded List of mandated roles March 2021 Ben Edgar-Attwell (10.2) Board level roles to ensure required. received from CoSec October Sam Hann network. Internal mapping 2021 exercise on hold currently due to work being undertaken by NHS Providers. Updates will be provided to individuals in due course ACTIONS FROM 7 JULY 2021 1-33/ Board item to be arranged to review and Reviewed by extraordinary October Sam Hann 2122 (9.3) approve 2020/21 Quality Account GQAC meeting held 19 2021 July 2021. Further amendments to be made during July/August ACTIONS FROM 4 AUGUST 2021 1-39/ Declaration of Interest Register to be updated Complete August Shelagh Meldrum 2122 (2.1) to reflect the change in role for Shelagh 2021 Meldrum’s husband 1-42/ Board presentation on the new cleaning Not yet due October Sam Hann 2122 (5.3) standards to be arranged 2021 1-46/ Tracy Jones to be invited to present the Not yet due December Sam Hann 2122 (9.2) Quarterly Wellbeing Guardian Report 2021 1-47/ Workforce Committee Terms of Reference to Not yet due October Sam Hann 2122 be presented to the Board for approval 2021 (10.2) 1-48/ Circulate to all Board members the annual Complete August Sam Hann 2122 reports and presentation slides which were 2021 (11.5) reviewed by the Governance and Quality Assurance Committee (GQAC) on 16 June 2021 and 27 July 2021 1-48/ All Non-Executive Directors to be invited to Not yet due June 2022 Sam Hann 2122 the Annual Report GQAC meeting (11.7)
Appendix: 3 REPORT TO: Board of Directors REPORT BY: Finance and Management Information Departments PRESENTED BY: Executive Directors EXEC SPONSOR: Executive Directors REPORT TITLE: Board Overview Quadrant DATE: 1 September 2021
Purpose of Paper (Please select any which are relevant to this paper)
☒ For Assurance ☐ For Approval / Decision ☒ For Information
Reason for Presentation to This Board Overview Quadrant provides an overview of the Trust’s Committee/Board performance on finance, quality, performance and workforce indicators, including:
. Income . A&E waiting times . Top up funding from NHS . Ambulance handover times England . RTT waiting times . Pay . Diagnostic waiting times . Non-pay . Cancer waiting times . Depreciation, Interest, PDC, . Infection control Impairments . Mortality . Financial Improvement . Incidents / Never Events Trajectory basis . Complaints and concerns . Donated Assets and . Friends and Family Impairment response rate . SOCI Position . Stroke performance . CIP Achievement . Readmissions . Capital . Staff turnover . Cash Balance . Staff vacancies . Appraisal rates
Members are asked to NOTE the report for assurance and information.
Any Key Issues to Note
Links to Strategic Priorities / Board Assurance Framework (Please select any which are impacted on / relevant to this paper) ☒ Care for our Population ☒ Develop our People
☒ Innovate and Collaborate ☒ Develop a Sustainable System
Implications/Requirements (Please select any which are relevant to this paper)
☒ Financial ☐ Legislation ☒ Workforce ☐ Estates ☐ ICT ☒ Patient Safety / Quality
Reference to CQC domains (Please select any which are relevant to this paper)
☒ Safe ☒ Effective ☒ Caring ☒ Responsive ☒ Well Led
Is this paper clear for release under the Freedom of Information Act 2000? ☒ Yes ☐ No
YEOVIL DISTRICT HOSPITAL FOUNDATION TRUST PERFORMANCE QUADRANT
FINANCE Jul-21 SAFETY AND PATIENT EXPERIENCE Jul-21
£0.140m in £0.161m adverse £0.132m year to £0.005m year to date fav to Indicators Jul-21 Jul-19 6 Month Avg Movement month deficit to in month plan date deficit financial trajectory HSMR (Latest available - Apr-20 to Mar-21) 0.950 0.860 -- -- Patient Falls 68 56 60.7 h Pressure Ulcers 4 1 5.2 g In Month (£'000s) YTD (£'000s) C.Diff (Lapse in Care) 0 0 0 g Variance to Variance to Trust Category - Core items Actual Actual E.Coli Gram Negative Blood Stream Infections 3 4 0.83 h Trust Plan Plan Income (Including Top funding from NHSE/I) 17,869 8 74,957 1,074 MRSA 1 0 0 h SIREN and COVID referred testing 199 199 701 701 Incidents reported 883 854 809 i Pay - Substantive, Bank & Agency (11,638) (49) (47,931) (302) Number of never events 0 0 0.00 i Non-pay - Consumables, Drugs, Other (5,879) (262) (25,274) (1,446) Number of prescribing errors causing harm 0 1 0.33 i Depreciation, Interest, PDC, Impairments (692) (56) (2,585) (21) Number of maternity serious incidents 1 0 0.33 h Financial Improvement Trajectory basis (140) (161) (132) 5 VTE risk assessment completed on admission 94.10% 97.19% -- i Donated Assets and Impairment (21) 3 (117) (20) Complaints 7 4 4 g I&E surplus/(deficit) (161) (158) (249) 14 PALS Concerns 51 62 37 i
Inpatients Friends and Family Test Response Rate (Statutory Return) 11.00% 29.60% -- -- Additional items Actual Variance Actual Variance CIP Achievement (to draft new year budget) 264 486 Inpatients Friends and Family Test Likely to Recommend (Statutory Return) 97.74% 99.09% -- -- CIP % achieved recurrent 84.0% Pay - Agency (925) (421) (3,581) (1,552) Rate of readmissions for the same clinical condition (% of total number of admissions) 5.03% 4.35% -- h Capital expenditure (1,261) (1,537) Working cash balance* 21,667 21,667 Number of same day cancelled operations for non-clinical reasons 25 13 -- h Better Payment Practice Code (BPPC) 95.3% Safe Staffing nurse fill rate (Number of wards at < 80% establishment) 0 0 -- g
PERFORMANCE Jul-21 PEOPLE Jul-21
Indicators Actual Local Target National Standard Movement RAG (Local) Indicators Jul-21 Jul-19 Target Movement RAG A&E 4 hour Waiting Times 90.74% 95.0% 95.0% i Turnover 14.66% 16.67% 12%-17% i Ambulance Handover Times 93.76% 98.0% 98.0% h Registered Nursing Vacancies (% of Whole Time Equivalent) 2.12% 3.05% 5.00% h RTT - Incomplete Pathways Waiting Times 71.23% -- 92.0% h Medical & Dental Vacancies (% of Whole Time Equivalent) 3.83% 2.66% 5.00% h Diagnostics - 6 Weeks Waiting Times 78.75% 99.0% 99.0% i Other Vacancies (% of Whole Time Equivalent) 5.98% 4.15% 2.00% h Cancer - 2WeekWait - Waiting Times (Jun-21) 94.29% 93.0% 93.0% h Total Vacancies (% of Whole Time Equivalent) 4.33% 3.57% 2.00% h Cancer - 2WeekWait - Breast Symptoms (Jun-21) 91.89% 93.0% 93.0% i 12 month Absence Rate (month in arrears) 3.51% 2.86% 3.00% h Cancer - 28 Day Diagnosis - 2WeekWait (Jun-21) 74.71% 75.0% 75.0% i Mandatory Training Rate 87.85% 88.40% 85.00% i Cancer - 28 Day Diagnosis - Breast (Jun-21) 97.30% -- TBC h Staff Appraisal Rate 86.53% 91.66% 90.00% i Cancer - 31 day Treatment Waiting Times (Jun-21) 98.10% 96.0% 96.0% i Agency Spend in Month against ceiling (£000's) £925 £588 £470 Cancer - 62 day Standard Waiting Times (Jun-21) 91.73% 85.0% 85.0% h Agency Spend YTD against ceiling (£000's) £3,580 £2,036 £1,880
RAG Status: Local Target achieved,Target failed - within 1% of local target, Target failed - more than 1% away from achieving local target
Appendix: 3 REPORT TO: Board of Directors REPORT BY: Victoria Keilthy, Director of Integration PRESENTED BY: Jeremy Martin, Director of Transformation EXEC SPONSOR: Jeremy Martin, Director of Transformation REPORT TITLE: Strategic Case for Merger with Somerset NHS Foundation Trust DATE: 1 September 2021
Purpose of Paper (Please select any which are relevant to this paper)
☒ For Assurance ☐ For Approval / Decision ☒ For Information
Reason for Presentation to Yeovil District Hospital NHS Foundation Trust (YDH) and Somerset Committee/Board NHS Foundation Trust (SFT) recognise the need for greater collaboration in order to meet the significant challenges faced by the health and care system in Somerset.
After detailed consideration of the available options for closer collaboration, the Board approved (on 4 November 2020) the development of a Strategic Case that would set out a proposal to merge the organisations and create a single NHS provider trust for Somerset to better support the health and care needs of the population.
The merger of the two Foundation Trusts provides the opportunity to create an organisation that is ground-breaking within the NHS, bringing together acute, community, mental health and some primary care services into a single legal entity. The merger also lays the foundation for further development towards our vision for the Integrated Care System in Somerset.
The Strategic Case sets out the high-level rationale for merging the two Trusts, the developing plans for how the merged Trust would operate, the expected benefits, and the next steps. Both Trusts continue to work closely with system partners as we develop our plans.
The Strategic Case was submitted to NHS England and Improvement in April 2021 and we have now received approval to develop a full Business Case.
The attached Strategic Case is being presented to the public Board of Directors in recognition of the public interest in our merger plans. Any Key Issues to Note At the time the Strategic Case was prepared, we planned to submit our full Business Case to NHSEI in November 2021. Since submission of the Strategic Case, the SFT and YDH Boards have agreed to extended the business case submission date by six months to May 2022 to provide time to conduct meaningful engagement with staff and ensure that views of staff and stakeholders help shape the structure and culture of the new organisation.
Links to Strategic Priorities / Board Assurance Framework (Please select any which are impacted on / relevant to this paper) ☒ Care for our Population ☒ Develop our People
☒ Innovate and Collaborate ☒ Develop a Sustainable System
Implications/Requirements (Please select any which are relevant to this paper)
☒ Financial ☒ Legislation ☒ Workforce ☒ Estates ☒ ICT ☒ Patient Safety / Quality
Reference to CQC domains (Please select any which are relevant to this paper)
☒ Safe ☒ Effective ☒ Caring ☒ Responsive ☒ Well Led
Is this paper clear for release under the Freedom of Information Act 2000? ☒ Yes ☐ No
Strategic case for merger of Yeovil District Hospital NHS Foundation Trust and Somerset NHS Foundation Trust
Case presented to boards September 2021
Contents
1. Executive summary ...... 6 Strategic rationale ...... 6 Consideration of options ...... 8 Clinical strategy for merged Trust ...... 8 Expected benefits ...... 11 Financial case ...... 13 Transaction execution ...... 13 Position without merger ...... 14 Conclusion ...... 14 2. Introduction ...... 16 Overview of the Trusts ...... 17 Corporate strategy for the merged Trust ...... 23 Somerset health system ...... 24 Somerset system challenges ...... 25 3. Strategic context ...... 29 Improving Lives in Somerset...... 30 Covid-19 context ...... 37 National strategic context ...... 38 Collaborative achievements to date ...... 42 Limitations of current position ...... 45 Case for merger ...... 45 4. Strategic options analysis ...... 48 Stakeholder engagement and support from Somerset ICS ...... 53 5. Clinical care and support strategy ...... 55 Overview of current service provision ...... 56 Clinical strategy for merged Trust ...... 58 The 5 system clinical aims ...... 65 Next steps ...... 94 6. Supporting strategies ...... 96 Operating model ...... 97 People ...... 98 Digital ...... 102 Estates and facilities ...... 106 Integrated governance ...... 111 Improvement & transformation...... 113 Clinical research ...... 115 Medical education ...... 116 Joint ventures and wholly owned subsidiaries ...... 116 How the merged Trust will address Somerset healthcare challenges ...... 116
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7. Expected benefits of merger ...... 118 Expected benefits of clinical strategy ...... 119 Patient benefits ...... 119 Benefits to the merged Trust...... 120 Colleague benefits ...... 121 Benefits to Somerset health and care system ...... 123 Approach to benefits realisation...... 124 8. Finance ...... 125 SFT financial performance ...... 126 SFT current performance ...... 127 YDH financial performance ...... 129 Historical System Performance and ICS Context ...... 131 Projected incremental merger savings ...... 131 Transaction and transformation costs ...... 133 Value for money case ...... Error! Bookmark not defined. Risks ...... 134 Finance and capital strategy ...... 134 9. Transaction execution ...... 135 Legal form of transaction ...... 136 Planning for Board and Council composition of merged Trust ...... 136 Plan to deliver transaction ...... 137 Outline transaction governance ...... 138 Resources and programme management ...... 139 High level benefits realisation strategy ...... 141 Risk assessment and management ...... 141 Legal advice sought ...... 142 Initial due diligence ...... 143 Competition analysis ...... 143 Stakeholder communications and engagement ...... 145 Appendix 1: Supporting submissions ...... 150 Appendix 2: Somerset health and care key challenges ...... 151 Appendix 3: Quality ratings and well-led reviews ...... 161 Appendix 4: Operational performance detail ...... 168 Appendix 5: Early identification of merger projects ...... 175 Appendix 6: Summary integration programme plan ...... 186 Appendix 7: Board director profiles ...... 187 Appendix 8: Assessment criteria and sub-criteria for options appraisal ...... 199 Appendix 9: Principles for our joint Estates Strategy ...... 202
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Abbreviation Meaning A&E Accident and Emergency BAF Board Assurance Framework BMA British Medical Association CAMHS Child and Adolescent Mental Health Services CCG Clinical Commissioning Group CEO Chief Executive Officer CESR Certificate of Eligibility for Specialist Registration CMA Competition & Markets Authority CQC Care Quality Commission CSF Commissioner Support Funding DCH Dorset County Hospital DHSC Department of Health and Social Care GDE Global Digital Exemplar ICP Integrated Care Provider ICS Integrated Care System KPI Key Performance Indicator LWAB Local Workforce Action Board MDT Multi-disciplinary team MIU Minor Injuries Unit MoU Memorandum of Understanding MPH Musgrove Park Hospital MSK Musculoskeletal Musgrove2030 Long term estates strategy for Musgrove Park site NED Non-Executive Director NHSEI NHS England/ NHS Improvement PCN Primary Care Network PDC Public Dividend Capital PDC Provider Development Committee PIFU Patient Initiated Follow Up PMO Programme Management Office PSF Provider Sustainability Funding PTIP Post Transaction Integration Plan RTT Referral to Treatment SDEC Same day emergency care SFT Somerset NHS Foundation Trust SHS Symphony Healthcare Services Limited SIDeR Somerset Integrated Digital Electronic Record SLA Service Level Agreement SPFT Somerset Partnership NHS Foundation Trust STEP Somerset Treatment Escalation Plan STF Sustainability and Transformation Funding SWAST South West Ambulance Service NHS Foundation Trust TSFT Taunton and Somerset NHS Foundation Trust VCSE Voluntary, Community and Social Enterprises WTE Whole time equivalent YDH Yeovil District Hospital NHS Foundation Trust YDH2030 Long term estates strategy for Yeovil District Hospital site
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Preface
Somerset is a relatively straightforward health and care system, currently containing two Foundation Trusts, a single CCG and coterminous Local Authority with vibrant and engaged Primary Care and strong relationships with the voluntary sector. Through the merger of our two Foundation Trusts we have the opportunity to create an organisation that is ground-breaking within the NHS, bringing together acute, community, mental health and some primary care services into a single legal entity, and which lays the foundation for further development towards our vision for the Integrated Care System (ICS) in Somerset.
In recent years, we have seen our health and care system adapt and evolve to meet the challenges we face but we have not gone far enough. Our population continues to grow in size with an ageing demographic and people are spending larger proportions of their lives in poorer health. Nationally, one in three patients admitted to hospital as an emergency has five or more health conditions, up from one in ten a decade ago. This is putting significant pressure on traditional services. While smoking rates in the county are decreasing, diabetes, obesity, dementia and mental health issues are on the rise. Faced with these challenges, as well as those from Covid-19, the case couldn’t be clearer for joining up and integrating care around people rather than around traditional institutional silos.
In common with the experience across England we have seen collaboration across health and social care take place at a pace and scale unimaginable even a little over a year ago. The pandemic has accelerated collaborative working in Somerset, enabling us to deliver outstanding care to those in need while at the same time radically changing ways of working, tackling local bureaucracy and becoming more integrated. Our merger aims to build on and formalise our commitment to collaborative working by creating a single entity that supports the adoption of new technology, new working cultures, and new approaches to solving historical problems.
Our new organisation will help the professionals who know best to do their jobs better, and simplify systems and processes that might slow down or even prevent them from doing their jobs in the way they would want to. It will put the power of digital and data at the centre of our decision-making, supporting us to join up and transform the care we provide to our population.
Our vision is to create a new organisation that:
provides outstanding care and support to the population we serve is underpinned by a population health approach with a focus on preventing disease and supporting individuals and communities to improve their health and resilience builds on our existing vibrant and positive culture to create the conditions for people to perform at their best supports neighbourhood-based working between the NHS, local government and other partners such as the voluntary sector supports technology-enabled innovation and the adoption of new models of care has democratic accountability to the population we serve, and delivers the best value for money.
Our aim is also to create an organisation that is able to adapt and take on new accountabilities as we further define and create our integrated care system; our overriding priority being to keep our system as simple and free from unnecessary bureaucracy as possible.
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1. Executive summary
Introduction and background
1.1 This Strategic Case sets out the high-level case for the merger of Yeovil District Hospital NHS Foundation Trust (YDH) and Somerset NHS Foundation Trust (SFT). YDH provides acute services in south Somerset, north and west Dorset and parts of Mendip and runs 15 GP practices1. SFT provides community and mental health services for the whole of Somerset, and acute services for the north, west and centre of the county and runs four GP practices.
1.2 The proposed merger will bring together all of Somerset’s acute, community, mental health and learning disability services, and around a fifth of primary care into a single NHS Foundation Trust. The merged Trust will be in a unique position to provide genuinely integrated mental and physical health care, spanning whole patient pathways.
1.3 Health and care services in Somerset are struggling to meet the increasing demands of an ageing population and a rising number of people with complex or long-term health conditions. We have begun work to modernise the model of care in Somerset but much of our resource is still focused on bed-based care, rather than community- based services that support early intervention. Bringing together our acute services into a single provider will enable us to maximise the use of our elective capacity and streamline pathways to improve equity of access and performance.
1.4 The Somerset health and care system is financially challenged. The historic reliance on bed-based care models, high access rates for acute care and the high cost base for acute services have led to a structural financial deficit. This will not be addressed through stretching, organisationally based, cost improvement plans. We need to change the way that services are delivered to the local population to support healthier lives and deliver high quality care in a sustainable way.
1.5 This Strategic Case sets out the high level rationale for merging the two Trusts, our developing plans for how the merged Trust would operate, the expected benefits, and the next steps we will take if we receive approval to move to Business Case stage. We are working closely with our system partners as we develop our plans, and our partners have provided formal letters of support for our proposed merger.
Strategic rationale
1.6 The scale of the challenge to improve health and wellbeing and reduce health inequalities in Somerset is immense and has been particularly highlighted by the Covid-19 pandemic. Furthermore, the pandemic response has shown that no individual organisation in Somerset has what it takes to respond to these challenges alone. We need to bring our skills, knowledge and resources in health together with those of our colleagues in social care, education, housing and the voluntary sector if we are to tackle health inequalities and enable our communities to thrive.
1 YDH group runs the GP practices via a wholly owned subsidiary, Symphony Healthcare Services Ltd. It currently has 11 GP contracts covering 15 sites.
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1.7 In May 2020, YDH and SFT signed a Memorandum of Understanding (MoU) in which the Trusts committed to work together for the benefit of the Somerset population by aligning the Trusts’ strategic goals and operational activities. The Trusts signed the MoU to improve services for patients, but it was not intended to be a permanent position. Moving towards acting as one Trust, but legally being two separate organisations, carries cost and time inefficiencies which are hard to justify in the long- term. There is also a risk of lack of clarity around accountabilities as we continue to integrate and blur organisational boundaries.
1.8 The success of our local joint working was recognised in December 2020 when Somerset STP was designated an Integrated Care System (ICS). ICS status facilitates our system working and enables us to collectively manage our resources to improve the health and care of the Somerset population.
1.9 Our ICS vision is to work together for the benefit of the Somerset population to provide a place-based, joined-up system of health and social care. The proposed merger is a key step in helping us realise this vision, and follows the creation of SFT in 2020 through the merger of Somerset Partnership NHS FT and Taunton and Somerset NHS FT.
1.10 The merged Trust and the local authority, Somerset County Council, would serve the same population – the 562,000 people living in the county of Somerset.2 This would put us in a powerful position to implement a population health approach, building on the strong existing relationships with the Council, the local voluntary sector, and non- integrated primary care. The proposed merger would simplify local system architecture and support us to implement new models of care to drive better health and wellbeing for the people of Somerset.
1.11 The removal of organisational barriers will make it easier to join up care between mental health and physical health clinicians in the south of the county, replicating what we have already achieved in the north and west of the county following the creation of SFT. It will also help us strengthen links between primary and secondary care, drawing on the learning from YDH’s Symphony vanguard programme, as well as enabling us to improve our contribution to prevention and health promotion activities.
1.12 The Covid-19 pandemic has placed unprecedented pressure on our services. The proposed merger gives us the opportunity to capitalise on the innovations made particularly in the early stages of the pandemic and embed them across the county. It is clear that work to deal with the consequences of Covid-19, including reducing the elective backlog and delivering the national vaccination programme will be required for some time – possibly for years. The proposed merger would put Somerset in a better position to assemble and manage the dedicated and flexible workforce necessary to provide Covid-related care into the medium and long term, alongside business as usual.
1.13 Merger will mean we are more resilient to future periods of pressure (Covid or otherwise) and give us greater capacity to flex and redirect our resources to areas of greatest need. It will also enable us to improve our offer to existing and potential colleagues and make the merged Trust a great and exciting place to work.
1.14 The two Trusts have a good history of collaborative working which has yielded benefits for patients and the Somerset system. However, there are limits in how far we can go in integrating services while we remain separate legal entities. Separate line
2 The merged trust would also serve c.35,000 patients living in north and west Dorset.
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management structures, budgets and policies create barriers and, even when these have been overcome at individual service level, they generate delay and unnecessary cost in realising the benefits of collaboration. The proposed merger will allow us to strip out these costs and increase the pace and scale at which we can drive systematic integration across our services for the benefit of patients.
1.15 The NHS Long Term Plan notes the need to accelerate the redesign of patient care to future-proof the NHS for the decade ahead3. The two Trust Boards believe strongly that we now need to merge and move to a single Board, budget and governance structure in order to maintain transformation in Somerset at the pace required.
Consideration of options
1.16 Between August-October 2020, the two Boards considered options for the future of their collaboration. The Boards created a longlist of options, agreed a set of selection criteria and after applying those criteria identified three shortlisted options:
Partnership Board: creating a forum to share learning, reduce variation and streamline clinical pathways. Key decisions would be ratified by the two Trust Boards; Strategic Group Board: the two Trusts would formally delegate some or all decision-making rights to a group board which would make strategic decisions on their behalf; Formal merger: merge the Trusts via a statutory transaction.
1.17 The Boards received independent support from Deloitte LLP in their consideration of the options. Deloitte concluded that we had omitted no material options from our longlist of options and that the shortlisted options met our agreed objectives for collaboration. Deloitte also interviewed Board members and external stakeholders to gather views and aid internal discussion about the options.
1.18 The two Trust Boards concluded that neither the Partnership board nor the Strategic Group board model would deliver the sustainable system change that Somerset needs, and that a single leadership team and board would be the most effective mechanism for realising the significant benefits to be had from closer collaboration. The two Boards therefore concluded that a statutory transaction was their preferred option.
Clinical strategy for merged Trust
1.19 We want to provide better health care to the people of Somerset, and to do this we believe we need to formally bring together our community, mental health and acute services right across the county. The two Trusts and their subsidiaries also provide primary care services from 19 sites (with a combined list size of 113,000) which would make the merged Trust one of the largest ‘at scale’ primary care providers in the country and offer further opportunities to improve and streamline services. Merger will enable us to increase the pace and scale at which we can integrate our services, and
3 NHS Long Term Plan, page 6.
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remove the barriers such as separate budgets, policies and processes that currently add unnecessary cost and delay to providing care.
1.20 The alignment of provision, across sectors, within the same organisation will enable us to drive a population health management approach to service delivery that will support people in Somerset to lead healthier lives and prevent the onset of avoidable illness. This is a key building block of the proposed clinical strategy and will also support closer working with partners, including primary care, the voluntary sector and the local authority.
1.21 Under our clinical strategy we will integrate services to support better patient care and experience, and improve colleague satisfaction and well-being. Working with partners we will streamline and standardise patient pathways to remove duplication and inefficiencies and provide care closer to people’s homes, where appropriate. Patients, their families and carers will only have to tell their story once, and clinical and administrative approaches will be consistent to support improved patient and carer experience. Throughout our clinical strategy how we use patient and colleague time will be a key measure of our success.
1.22 We will improve our support to people living with long-term conditions and with complex care needs, and offer genuine parity of esteem for mental health and physical health conditions regardless of the setting in which a patient first presents. We will work closely with commissioners to devote a greater proportion of the merged organisation’s budget to mental health and community services in line with the national strategic focus on prevention and care at home, in preference to hospital-based care.
1.23 The merged Trust will play a key role alongside ICS partners in further developing Somerset’s 12 neighbourhoods and 13 Primary Care Networks, and we will align our community-based work and inpatient care with them. We will provide increased support and advice to primary care, and work with partners to support prevention, self- management and early intervention to support independence and prevent escalation of health need.
1.24 Our clinical strategy will serve the Somerset system’s five health and care aims, which are set out below. We have already begun working up the detailed clinical integration projects through which we will deliver these aims:
Aim 1: Enable people to live healthy independent lives, to prevent the onset of avoidable illness and support active self-management Aim 2: Ensure safe, sustainable, effective, high quality, person-centred support in the most appropriate setting Aim 3: Provide support in neighbourhood areas with an emphasis on self- management and prevention Aim 4: Value all people alike and give equal priority to physical and mental health Aim 5: Improve outcomes for people through personalised, co-ordinated support.
1.25 Successful integration of patient pathways will require close collaborative working between all providers, including primary and social care, neighbouring Trusts, other public sector organisations and the voluntary sector. We have worked closely with partners to develop our initial plans and will continue to do so as we further develop our thinking.
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1.26 Estates is a key enabler to our plans. SFT has capital programmes to redevelop its mental health and community estate, and Musgrove2030 (part of the New Hospital Programme) for the redevelopment of its acute hospital site. YDH’s estates capital programme, YDH2030, aims to develop a new surgical centre, expand the Emergency Department and upgrade wards. These programmes will support the clinical strategy by modernising our estates and improving the safety and therapeutic value of our hospitals. Both programmes will be underpinned by a joint Estates strategy to be developed at Business Case stage.
Operating model and enabling services 1.27 Significant service and organisational change will be required to realise our vision for the merged organisation and the way we deliver care to the population of Somerset. To support this we will need to develop and implement an operating model that facilitates the required changes, including person-centred care and service integration. We will build on the best of what already exists in both Trusts to develop strong enabling services that underpin the delivery of the clinical strategy. These will include:
People, where we will develop a People strategy focused on recruiting, engaging and developing the diverse workforce that enables the delivery of our clinical strategy and the national People Promise. Digital, where combining two digital teams means we would be able to draw on the strengths of each Trust and create a larger pool of IT resource to be deployed flexibly across the county. YDH’s digital team has a track record in app development and process automation. SFT is a Global Digital Exemplar (GDE) and has blueprinted an integrated approach to digital procurement, development and implementation that has gained national recognition. We will implement integrated digital solutions in support of our clinical strategy. Estates and Facilities, where we have the opportunity to ensure our healthcare estate supports the effective and efficient delivery of high-quality healthcare. Integrated Governance, where we will use the vision and strategic objectives of the merged Trust as the framework for the oversight and assurance of all aspects of safety and quality in our service provision, and drive improvement and innovation through a shared learning framework. Improvement and Transformation, where we will pool our improvement and transformation resources and use it flexibly to address system priorities. This will enable us to seek collaborative solutions that make the best overall use of our combined resources rather than focussing on traditional siloed solutions. Clinical research, where a single organisation providing care to more than half a million patients across acute, community, mental health and primary care services would be a very attractive prospect for both formal research as well as improvement and innovation projects. Medical education, where both Trusts already have strengths. Merger would enable us to combine our medical education teams and associated facilities, and remove duplication, whilst building on the high quality of education and training.
1.28 The detailed design of our operating model will be informed by models that work elsewhere. We have already agreed the principles that will inform and provide a framework for the development of this operating model, and these are set out below. The operating model will:
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enable the realisation of the ambition set out within the vision, strategic objectives and the clinical strategy. This includes a population-centric approach, supporting physical and mental health care needs. support the development of an environment that enables colleagues to thrive in their roles and that is open and inclusive, whilst embracing and celebrating the individual identities of different services and teams. recognise the importance of neighbourhoods and localities to the delivery of health and care to the population, and that more specialist services will be managed at a level that makes most sense in terms of scale, efficiency and sustainability. incorporate clear ways of working with other local partners, including primary care, social care and the voluntary sector in a way that supports population health management and the integration of care. support the integration of services in a way that makes most sense to the people we serve, and do so in a way that is streamlined, consistent and efficient without unnecessary duplication. allow for flexibility to recognise the breadth and scope of the service portfolio and the range of care settings, whilst ensuring equity of access for patients, carers and families. support a data and analytics driven approach to service planning and population health management.
Expected benefits
1.29 Our commitment to improving the healthcare we provide to the people of Somerset and advancing population health is the principal driver for our merger. We will improve care primarily through direct improvements to the services provided to patients, carers and families, and by using the scale of the new organisation to support better health and prevention activities in neighbourhoods. Merger will also help by addressing recruitment challenges and creating an innovative merged organisation which will have better financial standing than the two existing organisations without merger.
1.30 As one entity with a single vision, strategy, budget and line management structure we will remove the disincentives to close working between colleagues in the two organisations, which currently cause delay and unnecessary frictional costs.
Quality benefits
1.31 Our clinical strategy will mean more people in Somerset are able to live the life they want and have better health outcomes. People will spend less time in healthcare settings and have more time to do what matters most to them. Individuals and the communities they live in will be more resilient, and people will exercise greater choice and control over the support they need.
1.32 As a single entity providing acute, community, mental health and primary care, on a footprint coterminous with the County Council we will be well-placed to take a population health approach. We will work with our partners to gather and analyse population health data which will inform our work to tackle health inequalities, tailor care to local needs, identify local trends in disease, and drive out unwarranted variation.
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1.33 Our clinical strategy will deliver better health outcomes through, for example, earlier intervention for healthcare needs, improved access and navigation through care pathways, and better support to people to self-manage their health conditions. Improved patient and carer experience will result from care provided closer to home, pathways that are easier to navigate, and greater emphasis on personalised care provided in accordance with people’s wishes.
1.34 Merger will help us manage rising demand for services through fewer emergency attendances and admissions, and fewer outpatient appointments than would be the case without merger. We expect to secure these benefits by increasing the care provided at neighbourhood level, integrating and streamlining patient pathways that span the two Trusts, and increasing advice and support to primary care and the voluntary sector.
Colleague benefits
1.35 We expect the merger to improve the wellbeing and motivation of colleagues through working in improved services, broader career opportunities, an enhanced training offer and a richer research environment. Where we have started to integrate services (eg in urology) we have already seen a reduction in spend on temporary staff as a result of improved recruitment. However, we need to put our joint working on a permanent footing if we are to sustain these early gains into the long term and spread the benefits systematically across all our services.
Merged Trust benefits
1.36 The merged entity will be more resilient during times of seasonal or other pressure due to its larger colleague base and increased infrastructure resources. It will also be better positioned to deliver a sustainable mass vaccination programme if annual Covid vaccinations become a regular feature of public health.
1.37 Our planned changes, including streamlined patient pathways and county-wide waiting lists will help us improve Somerset’s performance against NHS constitutional standards.
System benefits
1.38 As noted above, once merged we will be in a better position to work with our partners to implement a population health approach to gain deeper insight into the health needs of the people we serve. This will benefit not only the Trust but our system partners too.
1.39 By focussing as a system on prevention and early intervention, our planned changes will benefit our system partners through additional support to primary care, reduced social care costs (as a result of early intervention) and fewer ambulance conveyances than would be otherwise be the case. The merger will also put us in a stronger position to play our role as a local anchor institution and contribute to the social and economic development of the county.
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Financial case
1.40 Both Trusts have underlying deficits, and tackling the system deficit will require action by the whole Somerset system. Merger will enable financial savings to be made from reduced length of stay in community and acute beds, and better demand management from teams working in a clinically and operationally aligned way. Improved use of resources at the most cost-effective point in the patient pathway will increase productivity, reduce unit cost and allow for growth to be accommodated.
Transaction execution
Legal route to merger 1.41 This is a merger of equals with the two Trusts coming together for the benefit of the people we serve. The Boards carefully considered the options for effecting the merger (informed by legal advice) and, for time and cost reasons, decided their preferred legal route is merger by acquisition, where SFT acquires YDH.
Board composition 1.42 The merged Trust will have a revised constitution at the point of transaction. The Board of the merged Trust will draw Executive and Non-Executive Directors from both the YDH and SFT legacy Boards. We intend to hold elections to the Council of Governors of the merged Trust shortly after transaction date to fill any vacancies and ensure representation from the constituencies set out in the revised constitution.
1.43 The merged Trust will span a wide geography and provide a very broad range of mental health, community, acute and primary care services. We will ensure the Board of the merged entity has the necessary skills and experience to enable it to provide effective leadership and oversight of the enlarged Trust.
Plan to deliver transaction and integration 1.44 We have developed a detailed plan to deliver the transaction, which is owned by named Executive Directors from the two Trusts and managed by a joint programme management office. We have identified a range of initial projects focused on integrating individual clinical and support services across the two Trusts. The Trusts have well-developed internal expertise in project management and benefits realisation to support the identification and delivery of tangible and intangible benefits. We are using this expertise to support individual integration projects as well as prepare for merger itself.
1.45 Executives from both Trusts have oversight of progress towards the proposed transaction via a joint executive Programme Board. Key decisions relating to the proposed merger are made by the two Trust Boards. The two Councils of Governors are kept regularly updated on progress. ICS partners are kept informed through monthly Provider Development Committee meetings, as well as other ICS meetings. We have developed an integration risk register to identify and manage risks associated with integration of the two Trusts.
1.46 Subject to receiving the necessary approvals and support from our Boards, governors, NHSEI and local stakeholders, we plan to merge the Trusts in spring 2022. Our
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timetable for merger seeks to balance the need to move at pace for the benefit of the local population, while also managing the risk of distraction from business as usual and potential deterioration in patient care.
1.47 Given the tight timeline and the ongoing pressures of responding to the pandemic, the Trusts agreed to outsource the initial due diligence, which was conducted by external advisers.
Competition considerations 1.48 In discussion with NHSEI, the Trusts have considered whether a merger notification to the Competition and Markets Authority (CMA) is required. Currently, the CMA would have jurisdiction to review the proposed transaction. NHSEI have advised that if the Health and Care Bill is passed on the envisaged legislative timetable, and if the scope of the proposed provision exempting trusts from competition merger review does not materially change, it is likely that our planned transaction would be exempt from merger review by the planned completion date.
1.49 The Trusts consider a merger notification is not required as the proposed transaction does not appear to raise the prospect of a substantial lessening of competition (bearing in mind the factors used to assess the recent Bournemouth/Poole merger), and in any event is likely to be exempt by the time the transaction completes. The Trusts will stay in touch with NHSEI as the legislation and the transaction progresses to understand anything which may alter this position.
Position without merger
1.50 If merger were not to proceed the Trusts would continue to collaborate in the best interests of patients. However, this would continue to generate the delay and frictional costs that arise due to different management structures, policies, processes and budgets; the Somerset system can ill-afford either. The Trusts would continue to carry the risk that accountabilities are unclear in services which have already begun integrating. Without merger it would also be harder to reallocate resources away from acute services towards non-bed based community services, and full integration of all our services would take significantly longer to achieve.
Conclusion
1.51 We are ambitious on behalf of the people we serve and want to transform the way we deliver services to improve the health of the population of Somerset. Together with our ICS partners we want to better meet our patients’ mental and physical health needs now and in the future. We will do this by adopting a population health approach and a clinical strategy which provides integrated, equitable and personalised care, closer to patients’ homes, with a focus on prevention and early intervention.
1.52 Although we have seen benefits from closer working under our MoU, merger enables us to take forward integration at a much greater scale and pace than is possible while we remain separate legal entities. The two Boards strongly believe that a merger of the two Trusts is an essential enabler to making these planned changes a reality within the timescale required and would be a significant step forward in our ambitions for our Somerset ICS.
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1.53 This Strategic Case and its supporting documents are the result of significant effort by a large number of colleagues and system partners. The Boards of both organisations would like to thank everyone who has contributed to the development of our merger plans.
Guide to reading this document 1.54 The content of the Strategic Case is set out as below, (see Figure 1). A list of supporting submissions to this Case is at Appendix 1.
Figure 1: Chapter contents
Area Chapter Description
Strategic 2. Introduction Summarises the services provided by the two Trusts, and the Context to the challenges facing the Somerset health and care system. Trusts
3. Strategic Summarises the national and local strategic context for the context merger, including rationale for the proposed merger.
4. Options Sets out the work undertaken to assess the potential options for analysis achieving our strategic objectives, and how the merger was identified as the preferred option. How the 5. Clinical Sets out the developing clinical strategy for the enlarged merged strategy organisation, including examples of how care and patient Trust will experience will improve, and care quality enhanced. operate 6. Supporting Describes the principles for the merged Trust’s operating model. strategies Sets out the current challenges facing our key support services including People, Digital, Estates, Governance and Improvement and how merger will help address those challenges. Also sets out how those services will support implementation of the clinical strategy, and our plans for integrating the services should we receive approval to proceed.
Describes the expected benefits of the merger for patients and their families and carers, for colleagues, and the benefits for the Trust and wider Somerset health and care system. 7. Benefits Sets out the historical performance and current year financial forecast for the two organisations and the key financial risks.
8. Finance Delivering 9. Transaction Summarises the merger programme governance, transaction integration Execution legal form and timeline, and gives an overview of our approach to initial due diligence.
Sets out the pre-merger communication and stakeholder engagement strategy.
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2. Introduction
Summary of key messages This chapter provides an overview of Yeovil District Hospital NHS Foundation Trust (YDH), Somerset NHS Foundation Trust (SFT), and the local Somerset health and care economy. Key messages include:
YDH provides acute services to people living in south Somerset, north and west Dorset and parts of Mendip. It has two main subsidiaries: Symphony Healthcare Services Limited which operates 11 GP practice contracts in Somerset, and Simply Serve Limited which provides estates and facilities management services to the Trust and other clients in the UK. YDH employs around 2,500 colleagues plus a further 760 in its two main subsidiaries. SFT provides a wide range of integrated community, mental health and learning disability services for the whole of Somerset, acute services for people in the north, west and centre of the county, and some specialist services across the county and beyond. The Trust runs four GP practices in the west of Somerset. It employs around 8,900 colleagues. Both YDH and SFT are forecasting a breakeven financial position in 2020/21. However, these positions include Covid funding and are not reflective of the underlying deficits in both Trusts. SFT is rated ‘Good’ overall by the CQC. Yeovil District Hospital is rated ‘Good’, but the overall Trust rating is ‘Requires Improvement’ because of the Trust’s use of resources assessment. As part of the proposed merger we will bring together the Trusts’ GP practices into a single ‘at scale’ support mechanism for primary care. With a combined list size of 113,000 this would make the merged Trust one of the largest ‘at scale’ primary care providers in the country. The Trusts are part of the Somerset health and care system and are members of the Somerset ICS, alongside Somerset Clinical Commissioning Group, Somerset County Council, primary care and the local voluntary sector. The boundaries of the CCG and the County Council are coterminous, and with relatively few partners, the Somerset health and care system is one of the simplest in the country. The proposed merger would bring together all of Somerset’s acute, community, mental health and learning disability services, and around a fifth of primary care into a single NHS Foundation Trust, making the system simpler still. The key challenges for health and care in Somerset are: o Demography – an ageing population o Health inequalities - including lower life expectancy for people with mental health illness o Underlying rising demand for our services, exacerbated by the pandemic (eg pent up mental health demand) o Historic underinvestment in mental health services o An existing model which focuses resources on bed-based care rather than community-based services which support early intervention o Ongoing Covid-19 pressures o Workforce vacancies and the impact of hiring temporary staff o Challenges around meeting NHS constitutional standards o Financial pressures both within the Trusts and the wider Somerset system.
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Overview of the Trusts
YDH 2.1 YDH provides inpatient and outpatient services to c.210,000 people in south Somerset, north and west Dorset and parts of Mendip. The Trust’s main site at Yeovil Hospital has over 300 inpatient beds. It operates a 24-hour Emergency Department and maternity unit, alongside a wide range of acute and general medical services, including emergency and general surgery. The Trust is part of the Severn Trauma Network.
2.2 Symphony Healthcare Services Limited (SHS) is a wholly owned subsidiary of YDH which operates 11 GP practice contracts across 15 sites in Somerset (total list size c.88,000). The establishment of SHS was a key part of the south Somerset Vanguard Project, alongside the Symphony Programme which established new models of care operating across south Somerset. The Symphony Programme introduced Health Coaches and Complex Care Teams to support people to live independently, thereby providing more joined-up, personalised care and support, freeing up GP time, reducing ED attendances and reducing overnight hospital stays.
2.3 YDH has a history of outstanding performance against constitutional standards and was routinely amongst the top three acute trusts in the country for four-hour A&E performance in 2019/20. The Trust has had the highest response rate to the NHS staff survey of any Trust in the country for the last three years4, and the 2020 survey results placed YDH top in the country for colleague health and wellbeing for the third year running. The Trust also performs very well for its flexible working offer5, quality of support from immediate managers and work on equality, diversity and inclusion.
2.4 The Trust has a second wholly owned subsidiary, Simply Serve Limited (SSL), which provides estates and facilities management services to the Trust and other clients in the UK. It began operating in February 2018. A third subsidiary, Yeovil Property Operating Company Limited, has only minimal transactions.6
2.5 YDH employs around 2,500 colleagues7. In addition, SSL employs 371 people and SHS employs 389. In 2019/20, YDH met its control total of a deficit of £19.3 million, on group turnover of £195 million. By meeting its control total the Trust was able to secure £19.3 million of Provider Sustainability Funding (PSF) to offset its deficit, thus ending the year in financial balance. YDH is forecasting a breakeven position in 2020/21. This position is in line with funding arrangements under Covid and is not reflective of the underlying deficit. Factors contributing to the Trust’s underlying deficit position include diseconomies of scale due to size and rurality, the deficit position of SHS, and an element of excess operational costs.
4 65.4 per cent response rate compared to a national average of 43.4 per cent, 2020 NHS staff survey. 5 In the 2020 national NHS staff survey, 66 per cent of YDH staff said there were opportunities for flexible working patterns compared to a national average of 56 per cent. 6 Yeovil Property Operating Company was created to facilitate integration of primary care practices relating to Symphony Healthcare Services. Currently it handles only one practice property. 7 Headcount figure.
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2.6 YDH is near the border with Dorset, and is closer to Dorset County Hospital8 (DCH) than Musgrove Park Hospital.9 The acute care services YDH provides to a section of north and west Dorset patients (c.35,000 people) represents around 20 per cent of the Trust’s income. These cross-county patient inflows are most significant in the Emergency Department and services such as ophthalmology, dermatology and maternity. The Trust rents clinical space in The Yeatman hospital in Sherborne, Dorset for outpatient clinics and a theatre for ophthalmology procedures.
2.7 In recent years the Trust has been able to take on elective work in general surgery, orthopaedics and ophthalmology from SFT and DCH to help ease the waiting list for those specialties.
SFT 2.8 SFT provides a wide range of integrated community health, mental health and learning disability services for the whole of Somerset, as well as acute services for people in the north, west and centre of the county (population c.350,000) as well as more specialist services across the county and beyond. The Trust runs four GP practices in the west of the county (total list size c.24,000).
2.9 SFT was formed on 1 April 2020 when Somerset Partnership NHS Foundation Trust (SPFT) and Taunton and Somerset NHS Foundation Trust (TSFT) merged. The transaction was ground-breaking because it created the first trust in mainland England to provide integrated community, mental health and acute hospital services. The Trust was a finalist for Mental Health Trust of the year at the 2020 Health Service Journal awards.
2.10 SFT provides acute services from its main site, Musgrove Park Hospital (MPH) in Taunton, which has around 700 inpatient beds. The Trust also operates 13 community hospitals (with 190 beds), providing inpatient, outpatient and diagnostic services, and seven Minor Injuries Units. The Trust runs four dental access centres in Somerset (which served 4,500 patients in 2019/20) and provides primary care dental services at three sites in Dorset (which served 3,500 patients in 2019/20).
2.11 SFT’s community services are wide-ranging and include district nursing, stroke services, podiatry and diabetic eye screening. These services are provided in a range of settings including community team facilities, GP surgeries, local clinics, and patients’ homes.
2.12 SFT provides mental health inpatient services and specialist healthcare for adults with learning disabilities from ten mental health wards across four sites10. Its community mental health services include Talking Therapies, Early Intervention in Psychosis, a community eating disorder service, and services for patients with autism and personality disorder. The Trust is also an early implementer of the new model of community mental health services called Open Mental Health, (see paragraph 5.11).
8 DCH is run by Dorset County Hospital NHS Foundation Trust. 9 Yeovil District Hospital is 21 miles from Dorset County hospital and 28 miles from Musgrove Park Hospital. 10 SFT provides low secure and CAMHS inpatient care for the region.
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2.13 SFT cares for some people from neighbouring counties who live close to the county border. In 2019/20, the Trust treated around 3,200 people in total from across north Somerset, Devon, Bristol and BANES11.
2.14 The Trust employs around 8,900 colleagues12. It scored above average in 8 of the 10 themes of the 2020 NHS staff survey and particularly well on colleague engagement and the quality of immediate managers. The Trust was also among the top ten trusts in England for the lowest level of minority ethnic staff experiencing discrimination from colleagues/managers.13
2.15 SFT has not yet consolidated the financial position of its legacy Trusts (TSFT and SPFT) to generate a prior year financial position. In 2019/20, TSFT reported a deficit of £4.8 million, on turnover of £369 million which was in line with the Trust’s control total and enabled it to secure £18.4 million of PSF (which was £6.2 million above the agreed level) enabling the Trust to end the year in financial balance.
2.16 In 2019/20, SPFT reported a surplus of £3.3 million, on turnover of £187 million which was in line with the Trust’s control total and included £2.23 million of PSF.
2.17 SFT is forecasting a breakeven position in 2020/21. As this position includes Covid- related funding it does not fully reflect the underlying deficit. The Trust’s underlying deficit position is caused by factors including diseconomies of scale due to size and rurality, PFI financing costs14 and older estate which is more costly to run and maintain.
2.18 Key facts about the two Trusts are set out in Figures 2 and 3.
11 In 2019/20, SFT treated 868 Devon residents, 784 Dorset residents, 746 residents of Bath, North East Somerset, Swindon & Wiltshire, and 741 residents of Bristol, north Somerset & south Gloucestershire. 12 Headcount figure. 13 https://www.hsj.co.uk/workforce/revealed-trusts-with-the-worst-levels-of-discrimination-for-minority-ethnic-staff/7029705.article 14 The Private Finance Initiative (PFI) financing costs relate The Beacon Centre, SFT’s specialist cancer centre in Taunton.
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Figure 2: Key Facts – YDH FT
Figure 3: Key Facts – Somerset FT
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CQC ratings
2.19 The Care Quality Commission’s (CQC) ratings of both Trusts are set out in Figure 4. The CQC has not inspected SFT since its creation, so SFT’s ratings are the ratings given to its legal predecessor SPFT. SFT is rated ‘Good’ overall by the CQC. Yeovil District Hospital is rated ‘Good’, but the overall Trust rating is ‘Requires Improvement’ because of the Trust’s use of resources assessment. Musgrove Park Hospital is rated Good.
Figure 4: CQC ratings
CQC domain Taunton & Somerset Somerset Yeovil FT Somerset FT Partnership FT FT Safe Requires Requires Requires Requires improvement improvement improvement improvement Effective Good Good Good Good Caring Outstanding Good Good Good Responsive Good Good Good Good Well-led Good Good Good Requires improvement Use of Good n/a n/a Requires resources improvement Overall Trust Good Good Good Requires rating improvement Acute hospital Good n/a n/a Good overall rating (Musgrove Park (Yeovil District Hospital) Hospital)
SFT 2.20 At SFT, CQC’s inspection15 found leaders had the capacity, capability and commitment to deliver high quality, sustainable care. There was a clear vision and credible strategy for the future, a strong culture, good engagement with patients, staff, and stakeholders and significant strength in innovation and quality improvement.
2.21 At the time of the most recent inspections, particular areas of challenge at SFT related in acute services to management of waiting times; the safety of the anaesthetic cover out of hours (specifically in maternity and critical care services); and checking of emergency equipment. Areas of concern in community and mental health services related to nurse staffing levels; and risk assessments and crisis plans in Child and Adolescent Mental Health services (CAMHS).
YDH 2.22 At YDH, CQC’s inspection16 found leaders were highly visible, approachable and supportive to staff. The culture was strong and centred on people who use services, and there was a strong culture of reporting incidents to learn and improve. There was an emphasis in the Trust on the safety and wellbeing of staff, and staff felt positive and proud to work for the organisation.
15 Findings are from CQC’s inspection of Musgrove Park Hospital published March 2020 when Musgrove was run by SFT’s legacy organisation, TSFT. 16 YDH CQC report published May 2019.
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2.23 At the time of inspection, areas of challenge at YDH related to the completion of patient records, including risk assessments, and mental capacity assessments in both medical care and end of life care; and pressures on children’s services from patients with mental health problems which led, at times, to risks to the safety of the ward and the wellbeing of other children.
2.24 Further detail on the CQC’s findings and the Trusts’ actions is provided at Appendix 3. The Trusts’ latest CQC reports and the comprehensive action plans the Trusts have put in place to address the concerns identified are provided as supporting submissions to this Strategic Case.
Primary care
2.25 There are 65 general practices in Somerset within the 13 Primary Care Networks (PCNs). Both Trusts are already managing some Primary Care practices, and we expect this to continue and develop in the future. SFT operates four general practices. YDH, currently runs 11 practices across 15 sites through its wholly owned subsidiary, Symphony Healthcare Services (SHS). SHS is an ‘at scale’ primary care operating company that uses an innovative model to combine the benefits of scale while preserving the best of the independent nature of primary care.
2.26 As part of the proposed merger we will bring these practices together into a single ‘at scale’ support mechanism for primary care. With a combined list size of 113,000 this would make the merged Trust one of the largest ‘at scale’ primary care providers in the country. The Trusts have entered into a Memorandum of Understanding for SHS to provide oversight and management arrangements for the four practices operated by SFT, as a precursor to bringing the practices together within SHS. Alongside this, the merged Trust will also develop a new partnership with non-integrated primary care in Somerset.
2.27 There is evidence that the two Trusts’ support to primary care practices has reduced overall costs (eg through reduced bed days) and enabled some practices in Somerset to continue to operate when they would otherwise have been unable to do so. The Symphony data set, developed through the South Somerset Vanguard programme, enabled the impact on hospital emergency bed days to be tracked, and showed a 14 per cent reduction in non-elective bed days after 18 months of the new care models operating. The merged Trust will be well-placed to develop further insights from similar data sets.
2.28 Our ongoing work with primary care supports our focus on population health management through, for example, system-wide roles (see Figure 5), and by acting as a catalyst for new models of care which bring together community and acute services, primary care and the voluntary sector to improve patient care.
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Figure 5: Colleague perspective on system-wide role
Colleague perspective: Kat Dalby-Walsh, YDH “My role is a fusion: I’m Associate Director of Community Transformation at YDH, Clinical Director of Yeovil PCN and the SRO for Somerset LARCH collaborative (which works with care homes). My job is about joining services up for patient benefit and keeping people out of hospital unless they really need to be there. People rarely need just one health care professional or just one public service to help them. I sit at the synapses between organisations (YDH, care homes, primary care and Somerset CCG) and try to keep decision-making fluid and person-centered.
Roles like mine are the embodiment of integrated care and the multi-disciplinary approach. The merged Trust will need more roles like mine, to work between services and across organisational boundaries. We can support population health management through the creation of services targeted at specific groups eg high opioid users, because we’re able to bring colleagues from across the system together, and have the freedom to problem solve in the best interests of the people we serve. My work sometimes involves taking colleagues out of their normal working environment, and I love seeing the joy and professional satisfaction this can bring - I recently asked a GP to give Covid vaccinations to residents of a homeless hostel, and the visit kicked off a plan for regular health checks at the hostel because the GP could see the need and was inspired to act.”
Joint ventures
2.29 For several years, YDH and SFT have both been participants in three related joint ventures: Southwest Pathology Services LLP, SPS Facilities LLP, and SW Path Services LLP which together provide laboratory services for the NHS and other organisations across the south west of England.
2.30 In addition, SFT has a joint venture with Practice Plus, called the Shepton Mallet Health Partnership, to run a treatment centre, community hospital and minor injuries unit at Shepton Mallet. YDH has a joint venture with Prime plc called Yeovil Estates Partnership LLP to provide estates, infrastructure and service transformation. This joint venture has built a multi-storey car park at the hospital and new staff residences in Yeovil.
Corporate strategy for the merged Trust
2.31 The aims of the clinical strategy (set out in Chapter 5) will be central to the corporate strategy of the merged Trust, alongside the joint People strategy and other supporting strategies such as Digital, Estates, Finance, Improvement and so on. If we receive approval to move to Business Case stage we will develop an overarching mission, vision and set of values for the merged Trust.
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Somerset health system
2.32 YDH and SFT are part of the Somerset health and care system and are members of the Somerset Integrated Care System (ICS), alongside Somerset Clinical Commissioning Group (Somerset CCG), Somerset County Council, primary care and the local voluntary sector.
2.33 The boundaries of the CCG and the County Council are coterminous, and with relatively few partners, the Somerset health and care system is one of the simplest in the country. The proposed merger would bring together all of Somerset’s acute, community, mental health and learning disability services, and around a fifth of primary care into a single NHS Foundation Trust, making the system even simpler still.
2.34 Geographically, Somerset is one of the largest counties in England, with relatively low population density and significant distances between population centres. 48 per cent of the Somerset population live in a rural area (compared to the England average of 18 per cent).17 Travel times across the county are around two hours east to west, and one hour north to south at the furthest points.18 The largest towns, Taunton and Yeovil, each has a district general hospital, run by SFT and YDH respectively. In addition, there are 13 community hospitals runs by SFT, seven of which have a minor injuries unit.
2.35 The present configuration of services and the largely rural road network means many residents have long travel times between home and hospital. Figure 6 shows the distances between health facilities in Somerset.
2.36 At c.562,00019, the population of Somerset means patient numbers are high enough to support the maintenance of most specialist clinical skills on an economically efficient basis, although it is harder to sustain some smaller services across the county’s two relatively small acute hospitals.
2.37 19 per cent of people in Somerset have a long-term health problem or disability20. Despite recent changes to the mental health model to enhance community-based care, the model of healthcare in Somerset is still largely bed-based, with resources focused on the acute and community hospital-based provision. This means opportunities to intervene earlier and prevent escalation of need are sometimes missed.
17 Somerset CCG annual review 2019/20. 18 Travel time from the west-most town (Simonsbath) to the east-most (Farleigh Hungerford) is around 96 miles - 2hours 15min drive in light traffic. North-most Webbington to south-most Tatworth is 40 miles - around 1 hour in light traffic.
19 Office for National Statistics 2019 mid-year population estimates, April 2020. 20 Somerset CCG Annual Review 2019/20.
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Figure 6: Distances between Somerset health facilities
Somerset system challenges
2.38 Like many local health economies in England, Somerset is grappling with a combination of rising demand, workforce pressures and structural financial challenges.
2.39 The key challenges facing health care services in Somerset are summarised below. Further detail is provided in Appendix 2.
Challenging demography: o Around 25 per cent of Somerset residents (c.140,000 people) are aged over 65. This is significantly higher than the average for England of 18 per cent. By 2043, the percentage of over 65s in Somerset is predicted to increase to 33 per cent of the total population, against a national average of 24 per cent. In parts of West Somerset and Burnham-on-Sea, more than half the population is expected to be aged 65 or over by 2033. Older people make greater use of health care services than people of working age. This means the demands on the Somerset health and care system are proportionately greater than in a comparable area with the same total population but a more balanced demography. o Somerset has relatively fewer people aged 20-44 than the average across the rest of the country. This reduces the number of adults able to provide unpaid care for a close friend or relative.
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Inequalities: o 19 per cent of people in Somerset have a long-term condition or disability, and more than 15 per cent of young people in Somerset have special educational needs or a disability. o The average life expectancies of men and women with a mental health disorder are 19.7 and 17.5 years lower respectively than the rest of the Somerset population. o Somerset is in the worst quartile nationally for rate of suicide, and the county’s hospital admission rates for people who have self-harmed or misused alcohol are higher than benchmark. o Social deprivation creates and exacerbates ill health. The number of Somerset neighbourhoods classed as ‘highly deprived’ rose from 25 to 29 between 2015-2019, and around 47,000 people now live in such neighbourhoods. Around 1 in 10 households in Somerset is in fuel poverty, and 13 per cent of children in Somerset are growing up in a low-income household. Food bank use in the South West rose 63 per cent between 2013/14 and 2019/20 and has increased significantly further still as a result of Covid-19. o 48 per cent of people in Somerset live in a rural area. Public transport links are poor, and one in five Somerset residents aged 65 or over has no access to a car or van; the proportion is even higher amongst women. Rurality also contributes to social isolation and is linked to digital poverty.
Rising demand: o Acute: A&E admissions at SFT are expected to rise by 17.1 per cent by 2034. Similar forecasting work is currently underway for YDH but is expected to show a similar increase. Independent forecasting by consultants Factor 50 suggests aggregate projected growth in elective demand through to 2024 will be 1.6 per cent per year across Somerset. o Mental health: Research commissioned by NHSEI21 estimates that as a result of the pandemic, demand for adult mental health services could rise by up to 40 per cent. In Somerset, our current projection of demand for community mental health services in 2021-22 represents a 20 per cent increase on pre- covid levels, although the pandemic makes accurate forecasting demand very challenging. o Community: While total referrals for community physical health services in 2020-21 are expected to fall as a result of the pandemic, we expect demand will rise again in 2021-22.
Underinvestment in mental health services: NHS Mental Health Benchmarking shows that the number of adult inpatient mental health beds in Somerset is around the national average. However, funding for our adult community mental health services is in the lowest quartile nationally according to the 2019 benchmarking data. This lack of investment in mental health creates pressure on other parts of the system. For example, the number of admissions to our adult mental health inpatient beds per weighted head of population is amongst the highest in the country (fifth highest of 56 mental health trusts benchmarked), and Somerset has a comparatively higher level of emergency readmission within 30 days of discharge from an inpatient mental health bed.
21 https://www.hsj.co.uk/mental-health/mental-health-demand-could-rise-by-40pc-warns-nhse-research/7029085.article
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Resources focused on bed-based care: Although work to modernise the model of care in Somerset is underway (through the development of neighbourhoods, the intermediate care service, open mental health, and work with primary care), too much of our resource is still focused on bed-based care, rather than community-based services that support early intervention. Somerset is commissioned for 190 community beds. Although the available benchmarking data is somewhat out of date, it indicates that the number of community beds in Somerset per head of population is at best around the benchmark and more likely above benchmark. A clinical utilisation review in 2018 showed that 2 in 3 people in inpatient beds in Somerset could have been cared for in a less intensive setting if alternative services with capacity had been available.22 This finding was replicated by recent clinical reviews23 performed in January-February 2021 which found that 91 of 136 patients in Somerset’s community hospitals did not require bedded care and would have been better cared for in other settings.
Covid-19: Like the rest of the NHS, Covid-19 has placed the Somerset health and care system under extraordinary and unprecedented pressure. New infection prevention measures and staff sickness absence have made it harder to care for people both with and without the virus. Somerset’s elective waiting lists have increased during the pandemic and we know there is pent-up demand (especially for mental health services) from people too fearful to attend an appointment in a healthcare setting or who do not want to trouble the NHS while the pandemic continues. It will take years to recover from the operational and financial consequences, and Covid-related issues will continue to draw management time from business as usual for some time to come.
Workforce recruitment: o As at December 2020, SFT had 43 whole time equivalent consultant vacancies, representing a 12.5 per cent consultant vacancy rate (in specialties including Cardiology and Care of the Elderly), plus 31 other medical vacancies. Following recent success in recruiting to long-standing medical vacancies, particularly at senior level, YDH had only 4 consultant vacancies at December 2020. o As at December 2020, SFT had 216 whole time equivalent unfilled registered nurse posts which represents a vacancy rate of 9 per cent. As at December 2020, YDH had 4 whole time equivalent unfilled nursing posts (1 per cent vacancy rate). At the time of writing nursing staff shortages (some of which are Covid-related) have forced SFT to temporarily close wards at four community sites on patient safety grounds. o To maintain safe services, SFT spent £9.7 million24 in the 9 months to December 2020 on temporary clinical staff. YDH spent £6.7 million in the same period25. The high spend was driven in part by colleagues shielding, self-isolating or off sick as a result of Covid-19.
Performance: SFT is not currently meeting any of the four key national standards (4-hour A&E, Referral to Treatment, Cancer 62-day or 6-week
22 Care Utilisation Review, Aptean, 5/9/2018. 23 Practice development forums. 24 Between April-December 2020, SFT spent £8.500 million on agency staff and £1.219 million on locum staff. 25This includes agency costs for all clinical staff groups plus locum costs for non-training medical staff ie Consultants and career / staff grades. It excludes bank /locum costs for other staff groups and medical staff training grades.
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diagnostics). Prior to the pandemic YDH performed well against national standards; it is currently meeting the Cancer 62-day standard26 but not the other three key standards. Further detail on the Trusts’ current performance against key national standards is set out at Appendix 4.
Financial pressures: o Both SFT and YDH are forecasting breakeven positions for 2020/21. However, these positions include exceptional Covid funding, so do not reflect the Trusts’ true underlying financial positions. o In 2019/20 the combined system deficit was £9.7 million. However, this includes £44.0 million of national support funding. The Somerset system is forecasting a breakeven position in 2020/21, under the exceptional Covid funding arrangements. o Both Trusts’ underlying financial deficits are driven in part by diseconomies of scale due to size and rurality. Providers’ achievement of CIP targets are increasingly difficult to deliver year on year, and neither the Trusts nor the CCG in Somerset are likely to be financially sustainable in the coming years without transformational change to the way health services are delivered.
26 As at December 2020.
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3. Strategic context
Summary of key messages
This chapter sets out the strategic context for merger and our progress so far in integrating care. Key messages include: Somerset STP was designated an ICS in December 2020. As partners, we are committed to achieving our ICS vision: to support the people of Somerset to live healthy and independent lives, within thriving communities, and with timely and easy access to high quality and efficient public services when they need them. To deliver this vision we need to work effectively in partnership and transform the way we work. We need to join up our services and adapt our model of care to focus on population health. Population health management and the consequent reduction of health inequalities is key to our ICS approach to health and care, and to the merged Trust’s clinical strategy. We are already transforming services to centre on community-based care, providing care closer to people’s homes and supporting early intervention. We now need to go further to develop the care we provide at neighbourhood level and invest more in prevention. Our proposed merger and the clinical care and support strategy it will enable us to deliver are fully aligned with the NHS Long Term Plan and the 2021 Health white paper. In May 2020, the two Trusts signed a Memorandum of Understanding which committed them to work together for the benefit of the Somerset population by aligning strategic goals and operational activities. Collaborative working between YDH and SFT has yielded many benefits for patients and the Somerset system. However, despite good progress to date, there are limits in how far the two Trusts can go in integrating services while the organisations remain separate legal entities. We now need to put our collaboration on a permanent footing to quicken the pace and drive integration systematically across all our services, under the overarching framework set by our clinical strategy. Merger will allow us to increase the pace and scale at which we integrate care. It will enable us to implement new care models that are more responsive, less bureaucratic and costly, and bring care closer to patients and communities. Merger will also facilitate partnership working with primary care, social care and the voluntary sector. The merged Trust has a key role to play in delivering the ICS vision. It will be easier for the Trust, when it is a single entity, to redirect resources to support prevention and health promotion activity, tackle health inequalities and support communities to thrive.
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Improving Lives in Somerset
3.1 No individual organisation in Somerset is able, on its own, to address the health and wellbeing challenges that our population faces. We need to bring our skills, expertise and resources in health together with those of our colleagues in social care, education, housing and the voluntary sector if we are to tackle health inequalities and enable our communities to thrive.
3.2 In 2019, the Improving Lives in Somerset strategy set down the county’s vision for health and wellbeing in the coming decade. Working in partnership across the county our shared vision is to create:
A thriving and productive Somerset that is ambitious, confident and focused on improving people’s lives A county of resilient, well-connected and safe and strong communities working to reduce inequalities A county infrastructure that supports affordable housing, economic prosperity and sustainable public services A county and environment where all partners, private and voluntary sector, focus on improving the health and wellbeing of all our communities.
Fit for My Future: a healthier Somerset 3.3 Somerset’s strategy for health and care is called Fit for my Future: a Healthier Somerset. Drawing on the Improving Lives strategy, it sets out the contribution of local health and care providers to the overall Improving Lives vision. The Fit for My Future (FFMF) strategy27 was originally developed from the Somerset STP’s Five Year Plan. The FFMF vision is shown at Figure 7.
27 Fit for My Future: a Healthier Somerset – Case for Change; Somerset CCG and Somerset County Council; 12 September 2018.
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Figure 7: Fit for my Future vision
3.4 The clinical care and support strategy for the merged Trust (see Chapter 5) is based on the five health and care objectives of the FFMF strategy (see paragraph 3.13). Our strategy sets out in more detail the changes we will make within the merged Trust to deliver these five objectives. We are working closely with system partners as we develop our clinical care and support strategy, to ensure it remains wholly aligned with the FFMF strategy.
3.5 A key component of the FFMF strategy is the development of a neighbourhood model of delivery for the county, which is aligned with Primary Care Networks.
Neighbourhoods
3.6 As a rural county, Somerset has strong local identities and together with our system partners we want to support the resilience and social cohesion of our local communities. Our teams are working with other services and local communities in 12 neighbourhoods across Somerset, each consisting of around 30,000-50,000 people, see Figure 8.
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Figure 8: The twelve neighbourhoods in Somerset
3.7 The 12 neighbourhoods in Somerset are largely coterminous with our 13 PCNs, with the exception of the East Mendip neighbourhood which covers 2 PCNs: East Mendip and Frome.
3.8 Within these neighbourhoods, the ICS is bringing together primary care, community care and the voluntary sector to provide care closer to patients’ homes with the aim of maintaining wellness and intervening early to prevent escalation of mental and physical health need. The ICS believes that working through neighbourhoods will improve patient experience and support financial sustainability of public services. Some neighbourhoods are well advanced in their creation, e.g. West Somerset, East Mendip, Yeovil and South Somerset East, while others are still in relatively early development.
3.9 Commissioning locality profiles28 provide information to neighbourhood teams about local health needs and the wider determinants of health, and help them plan a broad- based, preventative approach to care in their neighbourhood.
3.10 As our PCNs and neighbourhoods continue to mature, we want to move more services out into communities and further strengthen and support place-based decision-making.
28 http://www.somersetintelligence.org.uk/commissioning-locality-profiles.html
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ICS vision for health and care
3.11 Together with our STP partners we were pleased to be designated an Integrated Care System (ICS) in December 2020. This change enables us and our partners in primary care, the ambulance service, Somerset County Council, and the voluntary sector to collectively manage our resources to improve the health and care of the Somerset population. Being an ICS supports us to develop new ways of working to deliver our strategic vision and to direct our combined resources to best effect in pursuit of that vision.
3.12 Together with our local partners, we are committed to achieving our ICS vision which is to support the people of Somerset to live healthy and independent lives, within thriving communities, and with timely and easy access to high quality and efficient public services when they need them.
3.13 As an ICS we have adopted the five FFMF system-wide health and care aims. They are:
1. Enable people to live healthy independent lives, to prevent the onset of avoidable illness and support active self-management.
2. Ensure safe, sustainable, effective, high quality, person-centred support in the most appropriate setting.
3. Provide support in neighbourhood areas with an emphasis on self-management and prevention.
4. Value all people alike and give equal priority to physical and mental health.
5. Improve outcomes for people through personalised, co-ordinated support.
3.14 To deliver this vision, we need not only to work effectively in partnership but also transform the way we work. We need to join up our services and adapt our model of care to focus on population health. Traditional bed-based services carry a treatment burden and risk of harm to patients and are no longer a sustainable way to meet the needs of our population. We are already transforming services to centre on community-based care, providing care closer to people’s homes and supporting early intervention. We now need to go further to develop the care we provide at neighbourhood level and invest more in prevention.
3.15 The merged Trust has a key role to play in delivering the ICS vision. It will be easier for the Trust, when it is a single entity, to redirect resources to support prevention and health promotion activity, tackle health inequalities and support communities to thrive. The Trust will also be able to apply its combined colleague, estates, digital and improvement resources to the pursuit of the ICS aims.
3.16 We are excited about the unique opportunity that bringing our two Trusts together offers to improve the health of the people of Somerset. Nowhere else in England has brought together the range of NHS services we plan to (mental health and learning
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disabilities, community, acute and primary care),1 and no other health and care system has just one NHS provider. However, the benefits of the proposed merger go beyond bringing our two Trusts’ services together: building on the existing strong partnerships with the local authority, primary care and the voluntary sector, the proposed merger lays the groundwork for fully integrated health and care support right across Somerset in a way that does not exist elsewhere in England.
3.17 Relationships in the Somerset health and care system were already good prior to Covid-19. For example, there was a wealth of joint working between primary and secondary care including MDT virtual meetings for cardiology, respiratory diseases and diabetes, Consultant Connect (advice and guidance to primary care clinicians from secondary care clinicians), virtual clinics for diabetes and Parkinson’s disease, Specialist Nurse support for GP respiratory disease clinics, joint Complex Care MDT community clinics for older people, and the ECHO29 palliative care projects which involve the voluntary sector (St. Margaret’s hospice).
3.18 When Covid struck, it created a strong sense of common purpose and required us to solve problems together in real time. This had the effect of further deepening our existing relationships and trust, see Figure 9.
Figure 9: personal reflection on Covid
Personal reflection: Shelagh Meldrum, Chief Nurse & Deputy Chief Executive YDH
A common enemy and a common cause
Undoubtedly when you face being hit by the largest global pandemic in living history with an already struggling NHS, as leaders you can choose two paths. Path number one, and perhaps one we would have followed some years ago, would be to batten down the Trust hatches and build an invisible wall where Trust business was the only business that mattered; this was not the path we chose to take. Path number two, became the chosen journey, where Covid-19 became the common enemy and survival became the common cause. This was absolutely evident throughout year one in our new “with-COVID world” where people across the system dropped their competitive and organisational guard and truly showed care and compassion towards each other and towards the organisations. There was absolute recognition that when trying, against all odds, to do your very best for the people you serve and the colleagues you work with isolation, in a new world of forced isolation is not the solution. Perhaps the greatest and most tangible example of this has been the way that vaccinations have been rolled out across Somerset with new teams forming, employment and personal barriers broken down, immense pride in each other’s contribution and an absolute sense of team achievement in pulling out all the stops to deliver. No one has felt alone, no one has felt done to and everyone has truly come together, across health, social care and the voluntary sector to deliver.
A quote from a member of the Somerset family on receiving their vaccine:
“I have just been to have my first jab and I have literally never seen anything like it. It was the most incredible operation you could possibly imagine. I am literally in awe of it. Even though there were hundreds of people passing through, it was so smooth and safe and every single person was unbelievably friendly. I know other people have probably said the
29 Extension for Community Healthcare Outcomes. The ECHO model operates in more than 20 countries and enables complex patients to access specialist care by moving knowledge rather than patients. Through video technology new medical knowledge is rapidly spread through healthcare systems from speciality care sites to community care providers. Community providers learn from specialists and from each other, and specialists learn from community providers as new best practices emerge. Community providers are able to use new skills they’ve learnt to treat people with complex long-term conditions that they would otherwise have referred out.
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same, but it honestly was incredible. It was so inspiring to see so many people from different teams working on it. Please pass on my congratulations to everyone – it was basically like an advert for the NHS – completely perfect.”
We have a common enemy, we have found a common cause – together we are better, stronger and more resilient.
3.19 Although the two Trusts have been working together for some time, merger will allow us to increase the pace and scale at which we integrate care. Merger will also facilitate system partnership working with primary care, social care and the voluntary sector, since there will be one organisation to engage with rather than two.
3.20 We are confident that merger will help us deliver the ICS vision because both Trusts are pioneers of integration: YDH’s Symphony programme introduced new models of integrated care to benefit people with complex needs; SFT was created to realise the patient benefits of integrating acute, community and mental health services. We are also confident that we can safely deliver this transaction as we have recent local experience of an NHS merger following the creation of SFT in April 2020.
Population health management
3.21 Population health management and the consequent reduction of health inequalities is key to our ICS approach to health and care in the county, and to the merged Trust’s clinical strategy. The King’s Fund defines population health management as:
“an approach aimed at improving the health of an entire population. It is about improving the physical and mental health outcomes and wellbeing of people within and across a defined local, regional or national population, while reducing health inequalities. It includes action to reduce the occurrence of ill health, action to deliver appropriate health and care services and action on the wider determinants of health. It requires working with communities and partner agencies.”30
3.22 The King’s Fund identifies four pillars of population health, see Figure 10. Improving population health requires action on all four of the pillars as well as the interfaces between them.
30 A vision for population health: towards a healthier future, The King’s Fund, November 2018.
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Figure 10: Four pillars of population health
3.23 The wider determinants of health are one of the four pillars of population health management. However, the influence that healthcare has on the wider determinants of health is limited – estimates vary from c.15-40 per cent, with the remaining influences consisting of social and environmental factors (eg education, housing, living and working conditions), genetics, and health behaviours (eg activity levels, nutrition, and how much individuals smoke and/or drink alcohol).31 This means we need to work with our partners in education, housing and social care, primary care and the voluntary sector if we are successfully to manage population health in Somerset.
3.24 Robust data and population analytics will be key to our ability to manage the health of the Somerset population. The two Trusts, along with Somerset County Council, have established a Collaboration Hub which will provide data and improvement expertise for the whole ICS. Analysis of population health data will provide insight into the needs of the Somerset population and help us tailor care to local needs, identify local trends in disease, and set investment priorities. Population health analytics will be at the heart of our strategic planning and inform our transformation and improvement work to tackle health inequalities and drive out unwarranted variation.
3.25 We are pleased to be participating in wave 3 of the Population Health Management programme run by NHSEI, which is helping us embed the population health management approach in our ICS.
31 A vision for population health: towards a healthier future, The King’s Fund, November 2018.
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Covid-19 context
3.26 The Covid-19 pandemic has placed unprecedented pressure on the NHS, and our services are no different. At the start of the pandemic the south west had the fewest critical care beds per 100,000 in the country32. The two Trusts’ ICUs provided mutual support as part of the regional network and helped each other at individual service level (eg Stroke). The creation of SFT in April 2020 meant it was easier to redeploy colleagues in community hospitals and community teams to support the provision of acute and intermediate care and introduce new care pathways. It also meant the role and perspective of mental health services has remained visible throughout the pandemic.
3.27 The Trusts also actively supported system partners during the pandemic. For example, SFT helped local care homes with their bank staff processes and gave them access to its bank staff to improve the resilience of their staffing situation.
3.28 It is clear that the work to deal with the consequences of Covid-19 will be required for some time - possibly for years to come. This work includes the national vaccination programme, responding to potential new vaccine-resistant variants of the virus, providing post-Covid rehabilitation care, responding to pent up demand (especially in mental health) and reducing the elective backlog. The vaccination programme is already a county-wide operation, and the Trusts are planning their elective recovery together. However, merger would put Somerset in an even better position to assemble and manage the dedicated and flexible workforce necessary to do this work on a sustainable basis into the medium to long term.
3.29 Merger will also mean we are more resilient to future periods of pressure (Covid or otherwise) and will give us greater capacity to flex and redirect our resources to areas of greatest need. The proposed merger gives us the opportunity to capitalise on the innovations made during the early stages of the pandemic, especially in the digital sphere, and embed them across the county.
ICS development
3.30 The proposed merger will enable us, together with our partners, to implement new care models that are more responsive, less bureaucratic and costly, and which bring care closer to patients and communities. Merger will facilitate data sharing across the system, and the merged Trust will have greater scope to act as a risk-holding entity to support primary care and VCSE33 development e.g. by pump-priming investment or supporting the attraction of greater resources into the county.
32 https://www.hsj.co.uk/quality-and-performance/revealed-huge-regional-variation-in-nhs-ability-to-meet-coronavirus- demand/7027153.article 33 Voluntary, community and social enterprise sector.
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3.31 Our proposed merger reduces the number of legal entities in the ICS and will make the ongoing development of our ICS governance simpler than it would otherwise be. Somerset is a simple system and we are keen to take forward discussions at national level about having just one NHS entity in Somerset, with a single Chief Executive Officer (CEO). This would minimise bureaucracy and support efficient partnership working with the local authority, non-integrated primary care and the voluntary sector.
3.32 Since the merged Trust would be the sole NHS Trust in the ICS, we anticipate that the clinical strategy set out in Chapter 5, which we are developing by working closely with our system stakeholders, will form the basis of the ICS clinical care and support strategy.
3.33 We also believe that merger will improve our links with neighbouring trusts (Dorset County Hospital, Weston General Hospital, RUH Bath, and the Royal Devon & Exeter) by providing a stronger, single voice for the county with consistent approaches and patient pathways.
National strategic context
Long Term Plan
3.34 The NHS Long Term Plan published in January 2019 set out an ambitious vision for the NHS over the coming decade. The Plan is clear that the NHS needs to deliver transformative change to meet the increasing demands of a growing and ageing population, while also maintaining and improving standards within the resources available. The proposed merger of the two Trusts presents an opportunity to drive such transformation and Figure 11 sets out how the merger would enable us to deliver the national ambitions set out in the Plan.
Figure 11: How our merger would meet NHS Long Term Plan objectives
NHS Long NHS Long Term Plan How our merger delivers the Plan objective Term Plan objectives chapter
Chapter 1 – Boost ‘out of hospital’ Somerset became an ICS in December 2020. The A new care, further integrate clinical strategy for the merged Trust takes a population service primary and community health approach and will provide person-centred model for services, reduce pressure equitable care, closer to people’s homes via more the 21st on acute emergency community-based services. The merged trust will play a Century services, and focus on key role alongside our ICS partners in further developing population health – the 12 Somerset neighbourhoods and supporting the 13 moving to Integrated Care Primary Care Networks (PCNs) by aligning our Systems everywhere. community-based services and inpatient care with them, (see Aim 3 of the clinical strategy, Chapter 5).
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NHS Long NHS Long Term Plan How our merger delivers the Plan objective Term Plan objectives chapter
Chapter 2 – Strengthened contribution Aim 1 of our clinical strategy sets out how we will provide More NHS to prevention and tackling increased support and advice to primary care, and action on health inequalities. support prevention and early intervention to prevent prevention escalation of health need. and health Aim 4 of our clinical strategy focuses on tackling health inequalities inequalities, including treating mental and physical health conditions equitably, regardless of the setting in which a person first presents (see Chapter 5). Chapter 3 – The Plan confirms the Aim 2 of the clinical strategy sets out our work to ensure Further need to continue to our services are high quality, sustainable, and person- progress address the biggest killers centred. Our merger plans include the creation of county- on care and disablers of the wide services which will help reduce overall waiting times quality and population, with a and facilitate the sharing of learning and best practice outcomes particular focus on within and between services. cancer, mental health, Aim 5 of the clinical strategy sets out our work to multi-morbidity and introduce personalised care, which will help people build healthy ageing including their knowledge, skills and confidence in managing their dementia, while health condition and ensure their care is focused on the intensifying the focus on things or outcomes that matter most to them (see children’s health, Chapter 5). cardiovascular and The merger enables us to bring together our paediatric respiratory conditions, and CAMHS services into county-wide services and learning disability and improve the focus on children in Somerset. In particular, autism. our ‘Function First’ programme seeks to improve the life chances of children with complex needs by increasing the time spent in school. Chapter 4 – The Plan recognises that As a single organisation we will be able to offer improved NHS staff in the past decade career opportunities to existing and potential colleagues will get the workforce growth has not through rotational working in different care settings. The backing kept up with the merged organisation’s increased patient volumes and they need increasing demands on wider base of services will enable us to boost colleague the NHS, which has led to capability, enhance clinical quality, and offer a richer and NHS staff feeling the more attractive research environment. strain. The Plan also The enlarged Trust will have increased team resilience recognises that the NHS with less risk of colleague burnout, and we will be able to has not been a sufficiently offer greater opportunities for flexible working and a flexible and responsive more comprehensive colleague wellbeing package (see employer. Chapter 6). Chapter 5 – The Plan recognises that We are already using digital technologies to enable Digitally virtually every aspect of better access to services, including virtual clinics with enabled modern life has been patients and multi-disciplinary discussions between care will go impacted by the digital clinicians. A patient portal will enable patients to manage mainstream revolution, but that the their own appointments, see results and provide online across the NHS has not yet been access to information to support self-care. NHS subject to a similar Multidisciplinary teams will be connected to information wholesale transformation. to support health and wellbeing, Planning and delivery of It provides a framework services will be improved, by adopting new technologies for investment in digital at scale, including robotic process automation and technologies for the future artificial intelligence to improve coding and other transformation of NHS processes. services. The Open Electronic Health platform and Somerset Integrated Digital Electronic Record (SIDeR) programme was soft launched in November 2020. It aims to provide a county-wide summary integrated care record accessible by clinicians, GPs, paramedics, out of
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NHS Long NHS Long Term Plan How our merger delivers the Plan objective Term Plan objectives chapter
hours/111, patients and wider health and care teams (see Chapter 6). Chapter 6 – The Plan recognises the Our aim to provide care closer to patients’ homes, where Taxpayers’ need to continue to drive clinically appropriate, is better for patients and reduces investment efficiencies in the NHS in costly bed-based care. The merger will also enable us to will be order to meet the deliver a level of support service savings which we could used to increasing demands of not achieve as separate entities. The estimated maximum the growing and ageing cumulative savings released by merger up to 2026/27 effect population, within the are £18.2 million, net of reinvestment in new models of agreed funding care, see Chapter 8. settlement.
NHS integrating care report
3.35 In November 2020, NHS England published ‘Integrating care: next steps to building strong and effective integrated care systems across England’ which builds on the Long Term Plan and signals a renewed ambition to support collaboration between partners in health and care.
3.36 The report encourages providers to collaborate across bigger footprints for better and more efficient outcomes, noting that “collaboration between providers (ambulance, hospital and mental health) across larger geographic footprints is likely to be more effective than competition in sustaining high quality care, tackling unequal access to services, and enhancing productivity”.
3.37 The merged Trust will be one of the largest employers in Somerset with the capacity to contribute to the social and economic development of the county not only by ensuring the health and wellbeing of the local population but also through its role as a significant local employer and owner of estates. Figure 12 below sets out how our merger meets the objectives set out in the Integrating Care report.
Figure 12: How our merger would meet NHS Integrating Care objectives
Integrating Care How our merger delivers the objective objective Improving Somerset ICS has committed to a model of care which focuses on population health population health. As a merged entity we will be in a better position to and healthcare work with ICS partners to drive improved population health and redirect our collective resources to the areas of greatest need. Tackling unequal Tackling health inequalities is the highest priority aim in our clinical outcomes and strategy – see Chapter 5, Aim 4. Under this aim we will address access inequalities in access to our services, as well as disparities in health outcomes for disadvantaged groups and health differentials arising from socio-economic factors, protected characteristics and geography. Enhancing We forecast that our merger will generate cumulative savings of £18.2 productivity and million up to 2026/27, net of reinvestment in new models of care (see value for money Chapter 8). Alongside these quantified savings we will increase productivity by removing interventions of low clinical value, and support colleagues to work at the top of their licence (see Chapter 6). We will
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invest in artificial intelligence to support quicker, more reliable clinical diagnosis, and paperless solutions to realise efficiencies, including automated self-service processes (see Chapter 6). Supporting Our clinical strategy values patient time and seeks to reduce the broader social collective patient time spent in poor physical or mental health (see and economic Chapter 5). This will promote the ability of the Somerset population to development lead socially active and economically productive lives.
The merged Trust will be a major employer in Somerset and will offer rewarding employment, including apprenticeships, with good career prospects and the opportunity to gain a professional qualification. We will continue to offer volunteering opportunities which help people develop new skills and remain socially engaged (see Chapter 6).
The merged Trust will be a major owner of estates and, through its ongoing estates redevelopment programmes, will create local employment and contribute to economic development (see Chapter 6).
As a merged Trust we aim to reduce our carbon footprint by 80 per cent by 2030 and be a carbon neutral trust by 2040. Fewer healthcare- related journeys as a result of our clinical strategy will lead to environmental sustainability and health benefits, and a lower carbon footprint for Somerset (see Chapter 6).
NHS White Paper 2021
3.38 In February 2021 the Secretary of State for Health and Social Care published a White Paper Integration and Innovation: working together to improve health and social care for all. The White Paper builds on the NHS Long Term Plan and aims to support recovery from Covid-19 by removing unnecessary bureaucracy, empowering local leaders and services and tackling health inequalities. Figure 13 sets out how the proposed merger supports the objectives set out in the White Paper. We have developed our case for merger in parallel with the development of our ICS. While the legislative environment remains dynamic, we are keeping a close eye on national strategic developments and will modify our merger plans as required.
Figure 13: How our merger meets the objectives of the White Paper 2021
White Paper objective How our merger delivers the objective
Working together to Our merger brings together into one organisation integrate care: help ICSs play all of Somerset’s acute, community, mental health a greater role in delivering the services and a significant proportion of primary best care, joining up different care. It simplifies our ICS and enables the merged parts of the NHS, and joining Trust to build on the already strong relationships up the NHS with local with the local authority, the voluntary sector and government to drive population non-integrated primary care. health and deliver The clinical strategy for the merged Trust takes a personalised care which population health approach and focuses on the tackles health inequalities. prevention of ill health, addressing health inequalities and delivering person-centred, personalised care. Merger will put us in a better position to work with our partners to implement
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White Paper objective How our merger delivers the objective
new models of care and address the wider determinants of health. Reducing bureaucracy: using Our county-wide SIDeR programme is one way we technology to better support are using the power of digital and data to improve staff and patient care; patient care, and the programme’s implementation removing the barriers that will be aided by the merger. prevent organisations from The merger will remove the different management working together in the best structures, policies and processes which can get in interests of service users the way of effective joint working between the two Trusts. Improving accountability The merged Trust will be a Foundation Trust, and enhancing public accountable to the population it serves via its confidence: Council of Governors and wider Membership. Our Ensuring systems are more constitution review group (see paragraph 9.9) will accountable and responsive to ensure the constituencies of the merged Trust the people that work in and reflect the population it serves. use them. As a merged Trust we will be better placed to deploy population health analytics to improve our understanding of local people’s health needs and configure services to respond to those needs.
Collaborative achievements to date
3.39 As ICS partners, YDH and SFT have worked closely for many years to support high quality care for the Somerset population. The pandemic has significantly accelerated our partnership working and shown what is possible when we work as a whole system to put the patient first, see Figure 14.
Figure 14: stakeholder perspective on vaccine roll-out as an example of integrated working
Stakeholder perspective: Dr Berge Balian, Chair of Somerset Primary Care Board “The Covid Vaccination programme is an excellent example of the collaborative approach to care provision that already exists in Somerset and demonstrates the determination of all commissioners and providers to create a truly integrated care system.
From the outset, it was agreed by the CCG, the County Council and all providers, including the voluntary sector, that there should be a system approach to the delivery of the Covid vaccine to the people of Somerset, irrespective of who was actually commissioned to provide the service. A Programme Board was established, comprising members from all providers and commissioners, tasked with the responsibility of delivering the vaccination programme. Staff from all providers volunteered to contribute to the programme and were released by their managers to be re- deployed where they were needed, coordinated through a centralised operational group. By ignoring organisational boundaries, we were able to use the county’s workforce in the most effective manner, deployed in community, hospital and county vaccination clinics.
As a result, Somerset became the top-rated Integrated Care System nationally, with 96.3 per cent of people over 80 and 93.4 per cent of people over 70 receiving their first vaccine by the middle of February 2021. The proposed merger of YDH and SFT will build on this collaborative approach, and further facilitate the integration of services for the benefit of the Somerset population.”
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3.40 In May 2020, the two Trusts signed a Memorandum of Understanding (MoU) in which they committed to work together for the benefit of the Somerset population by aligning strategic goals and operational activities. The MoU formalised collaborative working which was already taking place between the two Trusts. Examples of collaborative work already underway between YDH and SFT and our system partners include the following:
Intermediate care service: In March 2020, Somerset brought its existing county- wide Rapid Response34 and Discharge to Assess35 teams together with other discharge and diversion services under the umbrella term of Intermediate Care. Wherever possible the service supports people to remain at home. The service diverts up to 20 people per day away from hospital admission, and around 300 people a month are supported to leave hospital and return home sooner. Where it is not possible to support people at home, intermediate care supports over 200 people a month to complete their recovery in a bedded community re-ablement facility. John Bolton, a national social care expert, described the service as “probably the best developed set of arrangements for health and care in the UK”. We will need to continue to work as one NHS provider to enable the ongoing development and sustainability of this service.
Stroke: SFT and YDH’s stroke services have collaborated with social care and voluntary sector for a number of years to improve patient care and experience and respond to the rising demand for stroke care. The county-wide suite of ongoing stroke projects has led to a fall in the average length of stay in both acute and community settings36 and further integration of the services is planned (see Figure 30).
Oncology and Haematology: SFT and YDH’s oncology and haematology teams have been working together for several years, but the MoU and the move towards merger gave the teams more certainty and confidence to pursue greater collaboration. In 2020, the teams established four joint workstreams: workforce, clinical practice, acute, and elective, and in February 2021 they brought together the two Trusts’ helplines into a county-wide cancer patient helpline. The helpline reduces unnecessary GP appointments and emergency attendances from concerned patients and gives them direct access to specialist advice, and treatment if necessary. Both services have vacancies, especially in the medical workforce, and working together means the teams are able to deploy their collective oncology and haematology expertise in a way that ensures an equitable service for patients right across the county; it also helps them better plan for the future of the service as a whole.
34 Established in December 2018 the Rapid Response team supports people at home when they have a short illness that reduces their ability to look after themselves. Working closely with local voluntary organisations, such as the Red Cross, the service supports up to 20 new patients a day to remain at home. 35 Established in 2017 the Discharge to Assess service (formerly Home First) aims to reduce length of stay and delayed discharges of care. A dedicated team of nurses and allied health professionals assess a patient’s needs in their own home, community hospital or care home, and provide support until an ongoing out-of-hospital care package is in place. The team supports around 300 people a month to leave hospital. 36 The average length of stay at MPH’s acute stroke unit fell from 10.6 days in 2019/20 to 7.6 days in the period July-December 2020 (data gathering was paused from April to June 2020 due to Covid-19). The average length of stay at YDH’s acute stroke unit fell from 10.9 days in 2019/20 to 6.8 days for the period April -December 2020. The average length of stay in SFT’s two community stroke units fell from 40.9 days in 2019/20 to 33.6 days for the period April 2020-Jan 2021.
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Ophthalmology: In February 2021, the Trusts introduced a single point of access across key ophthalmology referral pathways. Following assessment of referrals, the single point of access refers patients to the Somerset provider with the shortest waits for treatment: YDH, SFT or Shepton Mallet Hospital (run by Practice Plus Group). The aim is to reduce waiting times across the county and better serve patients’ needs.
Urology: YDH and SFT’s urology teams came together in 2019 to address three key issues. Firstly, YDH’s urology service had a long-term vacancy for a consultant which it had been unable to fill on a substantive basis. Secondly, vacancies at YDH and retirements at Taunton meant it was difficult to sustainably provide 24/7 emergency urology cover across the two sites. And thirdly, at the time, YDH had spare capacity to help reduce the growing waiting list at Taunton. The two teams agreed the key principles under which the combined service would run, which included recruitment to joint posts covering both the Yeovil and Taunton sites. This change facilitated the recruitment of a consultant to fill the gap that YDH had been covering with a high cost locum. The combined team was also able to establish an out-of-hours county-wide consultant on-call rota, which has helped improve patient care, see Figure 19.
Pathology: Somerset was one of the first areas in the England to implement a local pathology network and shared service. YDH, SFT37 and Synlab set up Southwest Pathology Services (SPS) in 2012 as a joint venture to improve the delivery of pathology services. It now provides pathology services to over 500,000 people and more than100 GP practices. The network facilitated the centralisation of services and upgrades to equipment and processes which released ongoing efficiency savings. Since 2012 SPS has progressed further developments including the use of digital scanning of histopathology samples which allows remote reporting. The Trusts were one of the first users of this service in the NHS.
3.41 Under the MoU, YDH and SFT have also taken the following steps to integrate support services:
HR practices: steps to integrate the work of the two HR teams include joint work on health and wellbeing initiatives to support staff through the pandemic, joint line manager training, sharing of investigating officers and panel members for disciplinary procedures, and shared events hosted by our staff networks. YDH has also helped recruit staff for SFT under its Overseas Recruitment Programme (see Figure 42). Plans are underway to implement a single colleague support line and single exit interview portal across both Trusts. We plan to bring together our payroll provision later this year, and our medical rostering system in 2023.
Improvement team: Together with Somerset County Council the Trusts have created a Collaboration Hub to support the whole ICS. This enables us to use our Improvement resources flexibly to address system priorities and provide a system- wide view of progress on system programmes.
37 As one of its predecessor organisations.
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3.42 The Trusts have also worked in partnership on joint ventures for many years (see paragraphs 2.28-2.29), and YDH’s Simply Serve subsidiary currently provides facilities management services to a number of SFT sites in south Somerset.
Limitations of current position
3.43 Collaborative working between YDH and SFT has yielded many benefits for patients and the Somerset system. However, despite good progress to date, there are limits in how far the two Trusts can go in integrating services while the organisations remain separate legal entities.
3.44 The Trusts signed their MoU to improve services for patients, but it was not intended as a permanent position and the current position is unsustainable for the long-term. Each organisation continues to be accountable to its own Board, Council of Governors and population, and differing organisational interests and incentives can act as barriers to realising the full potential benefits of integration.
3.45 The challenges of different line management structures, policies, procedures, IT systems and cultures present barriers to implementing change and they generate delay and unnecessary cost to the system in realising benefits. As we move towards ever closer integration there is a risk of a lack of clarity over accountabilities – especially clinical – as we move to unify services and organisational boundaries become blurred.
3.46 In addition, separate budgets make our desired reallocation of resources within patient pathways (i.e. away from acute services towards non-bed based community services) more challenging, and fully flexible use of the combined estate is hampered while we are separate organisations.
3.47 At an individual service level, some colleagues have found ways around organisational barriers in order to integrate, and in that sense merger is not essential for integration of any individual service. However, we now need to put our collaboration on a permanent footing to quicken the pace and drive integration systematically across all our services, under the overarching framework set by our clinical strategy. It is this integration at scale that we will struggle to deliver in the absence of merger. Merger would remove existing organisational boundaries and free us up to integrate at the increased pace that the people of Somerset need.
Case for merger
3.48 SFT’s experience of merging SPFT and TSFT showed the value of bringing colleagues together into a single team, where ‘your success is my success’. When we are all on the same team, colleague relationships improve, and we are able to take a shared view of how best to structure services to meet patient need. In addition, when services
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span more of the patient pathway, executives and senior managers adopt a wider management lens in line with their new accountabilities, which also benefits patients (see Figure 15).
Figure 15: Personal reflection on the creation of SFT and the proposed merger
Tracy Evans, service director for neighbourhoods and primary care SFT Looking back on the creation of SFT There are endless benefits flowing from the creation of SFT. There is now a collective view of patients with a better understanding of flow. After bringing together mental health and physical health, our approach is less: “that’s your patient” and more: “how can we work together for that person and put them first?”
We’re thinking differently and not working in isolation. We’re able to influence more widely and have a more global perspective of healthcare. The SFT executive team has also benefitted from taking a wider leadership lens. And we have a collaborative system leadership ethos striving for a genuinely integrated care system. Collaboration between our different cultures has brought a richness to our approach.
On the proposed merger The proposed merger between SFT and YDH means we could offer equity, with the same principles in both hospitals. For example spreading the learning from YDH’s dementia team would provide a much more equitable service county-wide, and could bring workforce opportunities through rotational posts.
The proposed merger gives us a chance to improve co-production and engagement, and we could take the best from both Trusts - YDH are really good with their communication strategies and branding and at promoting best practice.
Merger would help us improve services for patients and enhance our neighbourhood working which prevents admissions, and bring prevention and self-management to the fore. It would strengthen governance and information sharing and reduce duplication as we could have one team for each pathway if we merged. Having one Trust would give us a unique branding and help us recruit and retain colleagues, and have a more inclusive offer for patients across Somerset.
3.49 The two Boards believe that becoming one organisation we will be able to realise fully the potential benefits of integration by:
Allowing fully integrated patient pathways to be established which will improve patient outcome and experience. Removing organisational barriers will increase the pace of these changes and help us engage with a wider set of colleagues and system partners in development of new models of care. Underpinning our shared corporate vision (to be developed) and drive a harmonised culture. Strengthening our actions to support our shared commitment to equality, diversity and inclusion. Signalling to colleagues and other stakeholders the permanence of the change and underscoring our commitment to realise the maximum benefits. Enabling a single governance framework to be established with clear accountabilities. Supporting agile decision-making and the fluid movement of resources across existing organisational boundaries (without frictional cost), so we can better meet clinical need. Facilitating full integration of support services.
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Boosting our resilience and creating additional capacity to respond to pressures (Covid, winter, environmental etc), staff shortages or other challenges, in part as a result of a greater focus on prevention and early intervention. Creating a provider in Somerset of sufficient scale to ensure its long-term sustainability.
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4. Strategic options analysis
Summary of key messages This chapter sets out the options the two Boards considered for the future of their collaboration, and the justification for the selection of merger as the preferred option. Key messages include: Historically YDH and SFT have had a constructive working relationship which has supported the provision of high quality care in Somerset. In May 2020, the two Boards signed an MoU committing them to explore options for further deepening their collaboration. In summer 2020 the two Trust Boards agreed a longlist of options for their future collaboration. The Boards also agreed the selection criteria which would be used to generate a shortlist of options. These criteria were based on the needs of the Somerset population and the local health and care system. The two Trusts commissioned Deloitte LLP to support them as an independent adviser on the options appraisal. As part of their work, Deloitte interviewed all members of both Trust Boards and representatives of Somerset CCG, Somerset County Council, Somerset GPs and the county’s voluntary sector. Interviewees recognised the significant benefits of future collaboration between the Trusts, and the majority acknowledged that creating a single legal entity through merger would be the most efficient mechanism for realising the desired benefits. Deloitte carried out an independent review of our longlist of options and concluded no material options had been omitted. They also concluded that our process to move from longlist to shortlist was evidenced-based and resulted in a shortlist that met our agreed objectives for collaboration. Deloitte also carried out an independent assessment of the advantages and disadvantages of our three shortlisted options, and they rated formal merger highest based on the criteria agreed by the Boards. In November 2020, both Boards formally approved merger as their preferred option for further collaboration. Our Somerset ICS partners, namely Somerset Clinical Commissioning Group, Somerset County Council, representatives of local GPs and the voluntary sector have provided letters of support for our proposed merger.
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Context for options appraisal
4.1 In 2016, Somerset STP set out its long-term aim to join up care across different parts of the health system and create an ICS38 in the county. The STP document set out the steps to achieve this aim, including closer provider collaboration in the interim. Since then, two of system’s Trusts, Taunton and Somerset NHS FT and Somerset Partnership NHS FT have formally merged to create SFT, leaving just two Trusts in Somerset.
4.2 YDH and SFT have historically had a constructive working relationship which has supported high quality care for the Somerset population (see paragraphs 3.39-3.42). In May 2020, the two Boards concluded that even closer collaboration between the Trusts would be in the best interests of the Somerset population and would be a vital step in the creation of an ICS, and signed an MoU to that effect (see paragraph 3.40). The MoU committed the Trusts to explore possible future options for deepening their collaboration.
Options appraisal process
4.3 In summer 202039 the two Trust Boards agreed a longlist of options for their future collaboration (see Figure 16). The Boards also agreed proposed selection criteria and a shortlist of options following application of those criteria.
Figure 16: Longlist of options for collaboration, and rationale for shortlisting
Option Detail Shortlist? Rationale
1. Do minimum Continue work to create a Provides the nationally-mandated ICS which may counterfactual to other include agreeing which of the two options which would be trusts would be lead provider required for a Strategic Case 2. Shared services Contractual arrangement for Does not fit national specified clinical services and strategic direction, and shared back office functions (under unlikely to be viable for SLAs). Legally both trusts remain; the long term due to one may be the lead provider. associated cost.
3. Shared Single executive team and one Unlikely to be viable for executive team operational organisation serving two the long term due to boards. Legally both trusts remain, burden on Executive with one acting as lead provider. team and duplication of costs (could however be used as a step to other options) 4. Shared Chair & Trusts remain separate legal entities More commonly used CEO with their own boards but share their when a strongly
38 At the time this was referred to as an Accountable Care System. 39 The YDH Board considered the longlist, selection criteria, and shortlist of options at its meeting on 29 July 2020. The SFT Board considered the longlist, selection criteria, and shortlist of options at its meeting on 12 August 2020.
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Chair and CEO who can influence performing trust supports the strategic direction of the two a poorly performing trusts and promote sharing of best trust, which is not our practice and integration of services. situation. (However, Can also work with just a shared could be used as step to Chair. One trust acts as lead other options.) provider.
5. Partnership board Partnership board offers a forum to Would support share learning, reduce variation and collaboration and allows streamline clinical pathways and other parties to join. corporate function but key decisions need to be ratified by individual boards. One trust acts as lead provider. 6. Strategic group A: The two trusts formally delegate Would support long term board some or all decision-making rights collaboration while to a group board which makes maintaining two trusts strategic decisions on their behalf. The trusts retain their sovereignty although their boards will have members in common. Delegated sub-Committees in Common also exist. One trust acts as lead provider. Establishing a JV that B: As above, but a joint venture is subcontracts to the trusts created to house the group board is bureaucratic and may and which acts as lead provider. result in additional VAT liability 7. Geographic Two trusts remain but acute, Would create two sub reconfiguration community and mental health scale providers within the services are restructured along county. Will result in geographical lines, with one trust fragmentation of services serving the East of the county, and and is counter to the the other the West. creation of Somerset FT 8. Merger The trusts merge to create a single Would meet MoU multi-site trust under single objective of single legal leadership and with a single board. entity Operations may be managed along site or service lines.
4.4 The detailed selection criteria the Trusts used to assess the options were based on the needs of the Somerset population and the local health and care system, see Figure 17.
Figure 17: Criteria for evaluation of collaboration options
Criteria Sub criteria Patient and service user Impact on safety and quality of care impact Impact on patient and service user experience Impact on long-term health outcomes
Strategic alignment Supports the development of the Somerset ICS Enables delivery of the joint clinical strategy Supports the development of neighbourhood working aligned to PCNs
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Enables system-wide estates and digital strategies
Clinical sustainability Impact on subscale services and resilience Impact on performance outcomes
Financial sustainability and Delivery of financial benefits that are greater than the ‘do value for money minimum’ Cost of implementation Sustainability of individual providers and the overall health and care system
Workforce and culture impact Enables development and implementation of a Somerset health and care system workforce strategy/People plan Impact on colleague satisfaction and wellbeing Impact on culture and local identity
Deliverability Ease of implementation Pace of benefits delivery Impact on ongoing operations
4.5 Following a competitive procurement process run in August 2020, the two Trusts commissioned Deloitte LLP to support them as an independent advisor on the options appraisal. There were four stages in Deloitte’s support for our options appraisal process:
An independent review of the longlisted options and process undertaken to arrive at the shortlisted options (the ‘critical friend’ review) An independent assessment of the shortlisted options against the assessment criteria Interviews during September 2020, with all members of both Trust Boards and four stakeholder representatives of Somerset CCG, Somerset County Council, Somerset GPs and the county’s voluntary sector Feedback sessions with both Boards individually, and a facilitated Board to Board meeting.
4.6 Alongside its ‘critical friend’ review, Deloitte provided two independent reports in September and October 2020 to aid the Trust Boards in their consideration of the options for collaboration.40 These reports are provided as supporting submissions to this Case.
Conclusions of independent review of longlist of options
4.7 Following their independent ‘critical friend’ review of our longlist of options, Deloitte concluded we had omitted no material options from the longlist. They also concluded that our process to move from longlist to shortlist was evidenced-based, had engaged
40 Deloitte’s first report dated 25 September 2020 was considered by the YDH Board on 30 September 2020 and the SFT Board on 6 October 2020. Deloitte’s second report dated 23 October 2020 was considered by the SFT Board on 3 November 2020 and the YDH Board on 4 November 2020.
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stakeholders from both Trust Boards and had resulted in a shortlist that met our agreed objectives for collaboration.
4.8 Deloitte advised the Trusts that further work was needed to develop the selection criteria to enable comparative and evidence-based scoring of the shortlisted options. We subsequently worked with Deloitte to further develop our assessment criteria so that the criteria included the features of low-scoring and high-scoring options. The result of this work is set out at Appendix 8.
4.9 Following discussion with Deloitte the Boards agreed that option 5: Partnership Board arrangement would become the ‘Do minimum’ option, and that option 1 (status quo but work towards an ICS) would be removed from the shortlist. The Boards decided to remove option 1 because it was considered unfeasible that collaboration of this nature would be acceptable to all parties without the appropriate governance oversight framework being in place to support the operation of the ICS, which would be akin to a Partnership board. This would be the case especially if one party assumed the role of lead provider. This left three options on the shortlist: Partnership Board, Strategic Group Board, or merger.
4.10 Deloitte also carried out an independent assessment of the longlist of options against the agreed selection criteria, and this confirmed the appropriateness of the shortlisted options.41
Conclusions of independent review of shortlist of options
4.11 Alongside seeking the views of Board members and stakeholders, Deloitte carried out an independent assessment of the advantages and disadvantages of the three shortlisted options using the agreed criteria and sub-criteria (see Figure 17 and Appendix 8). Deloitte applied a RAG rating to each sub-criterion and the summarised results are shown in Figure 18.
Figure 18: Independent assessment of shortlisted options
STRATEGIC GROUP PARTNERSHIP BOARD MERGER BOARD Patient and service user impact Strategic Alignment Clinical Sustainability Financial sustainability and value for money Workforce and culture impact Deliverability
4.12 Deloitte noted the low ratings for the Partnership Board are because the model requires high levels of alignment across partners as it is does not have any formal
41 The detail of this work is set out in Appendix B of Deloitte’s report dated 23 October 2020, which is provided as a supporting submission to this Case.
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decision-making authority and relies on goodwill between parties. Deloitte concluded this model would not successfully deliver the system change we want in Somerset.
4.13 The Strategic Group Board model rated more highly when it is assumed that there will be a Committee in Common with group functions and a site leadership model. This single leadership model allows good strategic alignment and can deliver significant improvements in patient and service user experience. The main challenges relate to the ability to deliver sustainable change as there is a risk that a decision is taken to undo the arrangement; this can have a particular impact on areas such as investment in transformational change and major capital investments. It can also be difficult to fully remove all duplication in governance arrangements.
4.14 Deloitte rated formal merger the highest in its independent assessment, noting that it would provide a single decision-making body under a common governance and operational model with the strategic alignment and authority to facilitate sustainable change. It could also be a material facilitator for the development of an ICS in Somerset.
4.15 The views shared by the majority of Board Directors and external stakeholders in their interviews with the Deloitte team were consistent with Deloitte’s conclusions from its desktop review of our shortlist of options. Interviewees recognised the significant benefits of future collaboration, acknowledged that a single leadership team and Board would be the most efficient mechanism for realising these benefits, and most believed that both Trusts should therefore be working towards creating a single legal entity through merger.
4.16 On 15 October 2020, the two Boards met jointly to build consensus on the way forward. The meeting demonstrated strong alignment between the two Boards, particularly in relation to the vision of creating a single entity to drive the creation of an ICS in Somerset, and the development of a Strategic Case for merger to take that forward.
4.17 In early November,42 each Board separately considered Deloitte’s second and final report which set out the findings from their independent reviews of our longlist and shortlist of option and the interviews with Board members and stakeholders. Both Boards approved merger as their preferred option for further collaboration.
Stakeholder engagement and support from Somerset ICS
4.18 We have engaged with our local ICS partners as our plans for joint working have taken shape, initially under the MoU, and now our proposed merger. Senior representatives from the local authority, the Somerset Primary Care Board and the local voluntary sector sit on our Provider Development Committee - the forum we have created to
42 The YDH Board considered the recommended preferred option at its meeting on 4 November 2020. The SFT Board considered the recommended preferred option at its meeting on 3 November 2020.
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oversee development of our merger plans (see paragraph 9.18). We invited comments from these stakeholders on a draft of this Case.
4.19 We have the support of our partners in the Somerset ICS for our proposed merger, namely Somerset Clinical Commissioning Group, Somerset County Council, representatives of local GPs and the voluntary sector. The letters of support from our ICS partners are provided as supporting submissions to this Case.
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5. Clinical care and support strategy
Summary of key messages This chapter sets out our developing clinical care and support strategy for the merged Trust (hereafter referred to as the ‘clinical strategy’) and how it will help the merged Trust play its role in addressing the challenges set out in Chapter 2. Key messages include:
Our clinical strategy puts the people we serve at the heart of our services. It supports our ICS population health approach and gives prominence to what matters to patients, carers, colleagues and communities. It values patient and colleague time, both in terms of minimising the time people spend in healthcare and maximising their years of healthy life. We will co-produce changes to our services with the people who use them. Senior clinicians from both Trusts are leading the development of the clinical strategy, with involvement from a wider group of more than 120 colleagues from primary care, Somerset County Council, Somerset CCG and the local voluntary sector, to ensure the strategy meets the needs of Somerset as a whole. We have also engaged with public and patient representatives to develop the strategy. Our clinical strategy in based on the current and expected future needs of the people of Somerset, the challenges the county currently faces in delivering consistently high quality, equitable and efficient care, and the opportunities for integration and improvement presented by the proposed merger. The clinical strategy will deliver the five agreed system-wide health and care aims:
o Enable people to live healthy independent lives, to prevent the onset of avoidable illness and support active self-management.
o Ensure safe, sustainable, effective, high quality, person-centred support in the most appropriate setting.
o Provide support in neighbourhood areas with an emphasis on self- management and prevention.
o Value all people alike and give equal priority to physical and mental health.
o Improve outcomes for people through personalised, co-ordinated support.
We will bring together all clinical services in the two Trusts into single county-wide services which will each have a single set of pathways and work to a single waiting list. Yeovil District Hospital and Musgrove Park Hospital will continue to provide emergency care 24 hours a day, 7 days a week. We have started to identify the projects and programmes that will deliver our clinical strategy. Our proposed programme of work is significant, and experience from other healthcare systems around the world shows that transforming services is a long-term project requiring 20 or more years to fully implement and embed.
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5.1 Our clinical strategy puts the people we serve at the heart of our services. The strategy supports our population health approach and gives prominence to what matters to patients, carers, colleagues and communities. It also values patient and colleague time, both in terms of minimising the time people spend in healthcare and maximising their years of healthy life.
5.2 The strategy facilitates the development of our ICS, as set out in Chapter 3 and is aligned with, and helps deliver, the FFMF strategy for health and care transformation in Somerset, including the ongoing development of neighbourhoods.
Development of our clinical strategy
5.3 We are developing our clinical strategy bearing in mind the current and expected future needs of the people of Somerset, the challenges the county currently faces in delivering consistently high quality, equitable and efficient care, and the opportunities for integration and improvement presented by the proposed merger. If we receive approval to move to Business Case stage we will refine and develop the strategy further.
5.4 Senior clinicians from both Trusts are leading the development of the clinical strategy, with involvement from a wider group of more than 120 colleagues in an ‘engagement group’ role. This group includes representatives from primary care, Somerset County Council, Somerset CCG and the local voluntary sector to ensure the strategy meets the needs of Somerset as a whole.
5.5 The clinical strategy for this merger builds on the strong foundations of the clinical strategy produced for the creation of SFT. However, we are now taking a wider lens than the SFT strategy did, as this current strategy includes our vision for care across all hospital settings and our deepening partnership with primary care. Mindful of recent developments in national strategic thinking, we have also worked with our system partners to ensure this clinical strategy is fit to form the basis of the clinical strategy for the wider ICS.
5.6 The remainder of this chapter is presented as follows:
Overview of current service provision in Somerset Our developing clinical strategy The merged Trust’s role in delivering the five Somerset system health and care aims Next steps in developing the clinical strategy.
Overview of current service provision
5.7 As noted in Chapter 2, care in Somerset is currently weighted towards admission to inpatient beds (both acute and community). This means some people are spending time in hospital care settings when more accessible local care and support would have
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been more appropriate had it been available. Inappropriate bed-based care exposes patients, especially the elderly, to the risk of hospital-acquired harm. Given our largely rural setting, a bed-based model also means some patients spend a significant amount of time travelling to and from hospital which can cause anxiety and inconvenience. Furthermore, the high cost of the current model makes it hard to invest in more local, flexible services based in communities.
5.8 The current provision of care has largely developed organically over time and is not integrated in a way that reliably meets people’s needs. Some pathways involve lengthy referral processes (e.g. to access a health coach for a patient seen in secondary care), have high thresholds for access to care (e.g. intensive dementia support), duplicate assessments (e.g. therapies), or use a care approach that focuses on discrete diseases when many people have co-morbidities.
5.9 Our healthcare services have an important role to play in the prevention of ill health, and there are opportunities for us to do more to prevent avoidable illness and disability at every stage of our care pathways. As we move towards ever closer working in aid of our population health approach, there is also scope for us to share our resources and expertise with partners.
5.10 Our 12 neighbourhoods in Somerset continue to develop and have an increasing range of resources and community solutions to draw on to help improve the health and wellbeing of their local population. However, we have more to do to publicise the existence of neighbourhoods and improve access to neighbourhood care. Furthermore, there are no direct referral routes from secondary healthcare services into neighbourhood health resources, meaning it is currently hard for healthcare professionals to help patients access this type of support.
5.11 Somerset is pioneering work to tackle health inequalities for people with mental health problems. Open Mental Health is a county-wide alliance of organisations working to ensure people with mental health problems get the right support at the right time. This includes specialist mental healthcare, housing support, debt and employment advice, peer support and more. However, addressing the deep health inequalities linked to poor mental health is a major programme of work that will take many years to fully implement, and there is still much to do to address the inequalities associated with mental health.
5.12 Life expectancy has fallen slightly in Somerset in recent years43 and morbidity is on the rise; people are spending larger proportions of their lives in poorer health. Our care for people with complex needs need to be personalised and well-coordinated so it focuses on what matters most to them and reduces their treatment burden. However, coordinating care remains a challenge in many healthcare settings, and the personalised care approach has not yet been implemented in all healthcare settings.
43 http://www.somersetintelligence.org.uk/life-expectancy.html
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Clinical strategy for merged Trust
5.13 Our health services will be centred on the people they serve, listening and responding to what is important to them and their loved ones. Healthcare colleagues will make sure people feel well supported and that their needs are clearly understood through active listening. We will co-produce changes to our services with the people who use them. There will be close collaboration between partners and a focus on learning and continuous improvement to get care right for everyone. This will not just be in terms of what care we provide, but also how we provide care, where and by whom. We will give prominence to valuing patients’ time, both with regard to the time they spend in healthcare and by maximising their years of healthy life.
5.14 If we get the go-ahead to merge, we will fully integrate the two Trusts’ services to improve the care and experience of the people who use them. We will integrate YDH’s acute services with SFT’s county-wide mental health and community services ensuring more effective pathways. We will also bring together YDH and SFT’s hospital-based care into single county-wide services, building on the best from both Trusts as we do so.
5.15 Working with partners we will streamline and standardise care pathways to remove duplication and inefficiencies, and break down the barriers that exist between health and care services. We want our pathways to be easy for patients, carers and colleagues to understand and navigate. Patients, their families and carers will only have to tell their story once, and clinical and administrative approaches will be consistent to support improved patient and carer experience. Our estates development programmes will focus on supporting quality of care and creating spaces for patients that have greater therapeutic value.
5.16 We will work closely with the developing neighbourhoods and provide more care in people’s homes and in the community. We will provide increased support and advice to primary care and ensure healthcare colleagues are able to help people access neighbourhood resources to improve their health and wellbeing.
5.17 We will also increase our work with partners to support prevention, self-management and early intervention to prevent avoidable illness and escalation of health need. For example we want to provide more specialist support to primary care and the voluntary sector, give information to people with health needs to help them self-manage, and ensure that at every stage we are taking steps to prevent avoidable illness and disability. Population health management will help us identify those groups most at risk of deteriorating health. We will also ensure people only receive bed-based care when it is right for them, to avoid harms such as deconditioning.
5.18 We will give equal priority to urgent and planned care, enabling waiting list recovery, preventing deterioration and ensuring that patients get the care they need in a timely manner no matter where they live in Somerset. By moving more care into neighbourhoods we will release capacity to continue with more elective care during the winter. We will give equal priority to treating mental and physical health conditions, and address other heath inequalities to ensure people get the care they need no matter
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who they are or where they live. We will also improve health outcomes, in particular for people with complex needs, through the provision of personalised, co-ordinated care.
5.19 Each clinical service in the merged Trust will become a single county-wide service, operating to consistent standards right across the county, with a single waiting list. This will reduce overall waiting times, improve quality and consistency (and reduce inequity of access), and make better use of our limited financial resources through increased scale, see Figure 19.
Figure 19: Development of single county-wide urology service
Case study: Urology YDH and SFT’s urology teams came together in 2019 and agreed key principles under which a combined service would operate. Following successful recruitment to joint posts, the next step is to move towards a single county-wide service across the two sites, with Musgrove Park Hospital providing emergency inpatient urology care, and YDH operating a 5-day/week elective service. This will help ensure equitable access to urology care across the county and ensure best use is made of the available elective capacity at both sites. The teams are also looking to standardise specialist nurse care across acute sites and community settings.
5.20 We believe that our patient-centred clinical strategy and the decentralised way we will implement it, will motivate colleagues and help create a great place to work. We also know that we cannot deliver population health on our own, so effective working with our partners in Somerset and beyond will be key to our success.
5.21 Our primary driver for merger is to improve the health of our population by improving the care we provide inside and outside of hospital. We believe that doing the right thing for patients will drive efficiency more effectively than focusing on cost saving schemes which bring the risk of poorer patient care and/or experience. The experience of other healthcare systems, e.g. Jönköping in Sweden, Canterbury in New Zealand and the Montefiore model in New York, has shown that an intense focus on the person and what matters to them, and making sure all elements of the system deliver the right care for people, drives down the cost of acute health services44 and improves health outcomes.45
5.22 As a merged Trust we will strengthen our relationships with other care and support providers in the county and beyond46, and work with them to understand where there are gaps in provision both in health and other services. We will support other agencies to do the right thing for the population of Somerset, to improve population health and benefit all involved. This may involve sharing resources with our local partners if that is the most effective way to serve the health and wellbeing of the people of Somerset. The Montefiore health system in New York has led the way on this with support for housing and community initiatives, recognising that these benefit both the patients who
44 Specifically, reduced admissions and readmissions to ED. 45 The Montefiore Health System in New York, Ben Collins, The King’s Fund, July 2018; The quest for integrated health and social care A case study in Canterbury, New Zealand, Nicholas Timmins and Chris Ham, The Kings Fund 2013; Population health systems: going beyond integrated care. Hugh Alderwick, Professor Sir Chris Ham, David Buck. The Kings fund 2015. 46 E.g. providers and commissioners in Dorset, Devon and North Somerset.
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receive the support and the health services which those people would otherwise access.
Valuing time
5.23 Valuing time - both patient and colleague time - is a key part of our clinical strategy. For most people the outcome they want from health and care services is to be as well as possible to be able to do the things that matter to them. That means spending as little time as possible in healthcare, and staying healthy for as long as possible. Furthermore, we want to explicitly value colleague time and make doing the right thing for patients, the easy thing to do.
5.24 We want to give time to patients through interventions which increase their healthy life expectancy and avoid taking time from patients through long waits or interventions of little clinical value. Many of our patients are older people in their last 1,000 days, and we are particularly committed to maximising the amount of high-quality time they have with their loved ones during the precious days at the end of life, see Figure 20.
Figure 20: Brian Dolan on valuing time
“For those with many more days behind them than ahead of them, it’s a time that’s not available to be wasted and while we may sometimes treat older people like they have all the time in the world, looked at differently, they are the ones in a hurry.” Professor Brian Dolan
5.25 We intend to use time as our primary measure to ensure people are spending the right amount of time in healthcare settings. This supports our focus on putting patients at the heart of our services and maximising the time they have to do what matters to them. Using time as a measure allows us to focus on the dignity and autonomy of the people we serve, as well as demonstrate our humanity and compassion. Time is simple to understand and is engaging for patients and colleagues alike. It also supports our aim of making the right thing the easy thing. Some of the ways we will demonstrate our commitment to valuing patient and colleague time are set out in Figure 21.
Figure 21: Valuing patient and colleague time
Valuing patient time means we will: Valuing colleagues’ time means work to increase healthy life expectancy we will: act early to prevent avoidable illness maximise the time colleagues reduce the period between the time of need and the spend on patient interventions fulfilment of that need (ie waiting times) and training streamline pathways to reduce waits and time spent in maximise time spent working at healthcare the top of their licence to make safely reduce the time spent in hospital having treatment best use of colleague skills reduce the time spent waiting for diagnostic results support colleagues in avoid non-value adding healthcare interventions, and determining how much time unnecessary follow-up appointments patients need to spend in health reduce the treatment burden eg arising from care interventions and in taking polypharmacy calculated risks if that promotes self-management for patients
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reduce the time spent accessing and navigating reduce bureaucracy to the healthcare minimum and remove non-value streamline administrative procedures and remove adding tasks. duplication so patients only have to tell their story once reduce unnecessary travel to receive healthcare.
5.26 We already collect data about time spent in healthcare processes, e.g. length of stay in hospital, number of outpatient appointments, number of home visits for treatment etc. We will work with system colleagues to supplement these with indicators of increased healthy life expectancy, via changes such as lower body mass index, increased physical activity, reduced alcohol intake and smoking cessation.
Optimising hospital-based care
5.27 The people who use our hospitals, and what matters to them, will be at the heart of how we run our hospitals. We will value the time of all, including the people with healthcare needs, their carers, and our colleagues. We will make sure our hospitals are safe, therapeutic centres which promote equity and good mental and physical health, and are accessible to all.
5.28 Some healthcare interventions can only be delivered in hospital settings, and it will be only for these interventions that people come to our hospitals. We will ask ourselves the question ‘Where best next?’ for all those who are in our beds. Bed-based care exposes patients to the risk of hospital-related harms such as infection, delirium and deconditioning. Hospital attendances also create cost and inconvenience for those patients and carers who have to travel a long distance to get to hospital. For these reasons we want to make sure people do not have to travel any further than necessary to receive care nor spend more time than necessary in hospital.
5.29 The evolution of mental health care in recent decades has shown that much healthcare can be delivered at home, or very close to patients’ homes. The use of technology during the Covid-19 pandemic has made this advance even clearer and demonstrated that it can be applied to some aspects of acute care as well.
5.30 Our intention to provide more care closer to patients’ homes means that we may repurpose some of the estate at SFT’s community hospitals to support delivery of our clinical strategy. For any significant proposed changes that meet the statutory requirement we will work closely with Somerset CCG to carry out appropriate public consultation.
5.31 Where the nature of the intervention means patients need to attend one of our mental health wards or acute or community hospitals, we will aim to deliver care during the day and then support people to return to their own home at night, to recover in familiar surroundings. For patients who need to stay overnight, our hospitals will have high quality wards which preserve privacy and dignity and provide a therapeutic environment which promotes recovery. Ward teams will link closely with the
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neighbourhood teams, to help people get back home as soon as possible, with the necessary support in place.
5.32 To deliver our vision for neighbourhoods (see paragraphs 5.101-5.103), we need to continue transforming existing community services. Our community hospitals will operate as community hubs within their neighbourhoods, and link with the two acute hospitals in Yeovil and Taunton.
5.33 Our community hospitals will provide services based on the needs of the local community and these will be delivered by an appropriate blend of health care professionals such as peri-operative practitioners, diabetes nurse specialists, open mental health workers, rapid response team members, district nurses, and primary care staff working alongside voluntary sector colleagues. The community hospitals themselves will be welcoming, accessible and easy to navigate for all, including for people with dementia and those with mobility or language difficulties.
5.34 Some services that we currently deliver in acute settings will in future be provided from community settings. Not every community hospital will have inpatient capacity – this will be determined by local needs. This aspect of our clinical strategy will require us to work closely with commissioners to increase the proportion of our resources devoted to non-bed based community care, including engaging in public consultation where necessary.
5.35 The patient discharge pathways from the two acute hospitals into the community hospitals are currently different. Removing the barriers between the two organisations and working as one team will help engage colleagues and build the trusted relationships which will be necessary to bring our clinical vision to life.
5.36 As part of the creation of SFT, a range of projects were implemented aimed at using community hospitals to provide care closer to people’s home and relieve pressure on acute services. This included conducting ophthalmology investigations at community hospitals and increasing community diagnostic capacity. If we get approval to proceed to business case we will explore ways to extend this approach by making use of SFT’s community estate in south Somerset to support YDH and relieve pressure on its acute services.
Urgent and emergency care
5.37 Yeovil District Hospital and Musgrove Park Hospital will continue to provide emergency care 24 hours a day, 7 days a week. Both Emergency Departments will have access to all the services necessary to support their work. In addition, SFT has seven minor injuries units based in community hospitals.
5.38 Whenever possible, patients needing emergency care will be treated on the same day if this is the best thing for them. After their treatment or therapy our community and neighbourhood services will provide support, if needed, to enable people to return home for their period of recovery. This community support could also include ongoing
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treatment, e.g. setting patients up to take intravenous antibiotics at home instead of remaining in hospital. Merger offers the chance to improve our urgent and emergency care, see Figure 22.
Figure 22: Colleague perspective on emergency care
Colleague perspective: Dr James Gagg, Consultant in Emergency Medicine, SFT “Merger makes sense to me because we’re already doing so much with YDH colleagues and others in the Somerset system to look at urgent and emergency care in an integrated fashion. When you have two emergency departments (EDs) and associated acute services doing the same thing it makes sense to have just one acute voice linking into the wider system. Yes, the two EDs have slightly different approaches but we‘re both working to the same end. The more we can share information and ideas the better it will be for patients. For example, YDH is a real leader in Same Day Emergency Care (SDEC) and I’m listening and learning from their success to help improve the SDEC offer at Musgrove Park.
Somerset is a big geography and we’ll always have an ED at Yeovil and Taunton, with local ownership and nuances which reflect the needs of the local population. However, simplified and unified processes for emergency care, with consistent pathways, and the ability to take the Somerset-wide view of services will be really beneficial for patients. And when we have a Somerset-wide view of patient records, we’ll be able to keep things more local, by conveying people with a medical emergency to their nearest ED rather than the hospital where their consultant works, as sometimes happens now.
We struggle to fill some ED vacancies, especially middle grades, and merger will also enable us to make a more attractive offer to potential recruits, for example through roles that span both EDs and offer wider professional development opportunities from work in the two settings.”
Plan on a page
5.39 A summary of the clinical strategy for the merged Trust is shown in our ‘plan on a page’, see Figure 23. We will continue to develop this plan on a page as our clinical strategy develops. We have started to identify the clinical integration projects which we will take forward as part of the proposed merger. This early thinking is set out in driver diagrams in Appendix 5.
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Figure 23: Clinical strategy plan on a page
5.40 As a system, we want to provide care at the lowest level appropriate for the person’s needs, starting with self-management and only escalating through increasing levels of
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care if the person’s health needs require it. Our clinical strategy supports the tiered approach to health and wellbeing agreed by the Somerset system, see Figure 24.
Figure 24: Levels of care to support health and wellbeing in Somerset
The 5 system clinical aims
5.41 As noted in Chapter 3, we cannot deliver the Somerset system’s five clinical aims on our own, and the merged Trust will need to work closely with system partners to deliver them. This section sets out the role the merged Trust will play in delivering the five Somerset system clinical aims. For each aim we set out the problem and changes we plan to make, how merger will help, and the benefits to patients, colleagues and the wider Somerset system.
Aim 1: Enable people to live healthy independent lives, to prevent the onset of avoidable illness and support active self-management
5.42 The intention of this aim is to promote healthiness and independence, avoid illness and harm, and support active self-management and patient empowerment. Of the five aims, this one requires the greatest partnership working because, as noted in paragraph 3.23, healthcare is only one of several influences on the wider determinants of health.
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Aim 1: What’s the problem?
Helping people to live healthy independent lives
5.43 Social isolation and loneliness47 are increasing in society and have been exacerbated by the pandemic. Research conducted before the pandemic predicted that without action loneliness will reach epidemic proportions by 2030.48 A meta-review of the impact of social isolation on mortality found that social isolation is comparable in its impact on mortality to other well-established risk factors for mortality.49 This fact is drawn on by the authors of a recent book about a Somerset GP project which reduced emergency admissions to hospital by 14 per cent between 2013-201750 through the support and creation of mutual support groups in the town of Frome (see Figure 25).
Figure 25: the value of social connectedness
“good social relationships have a greater effect on extending length of life than do measures such as giving up smoking or drinking alcohol, maintaining a healthy diet, taking regular exercise, weight loss or the treatment of high blood pressure.” page 43
“the [Frome] project has shown...that better healthcare and well-being within a community is not about more or better medicine and requires neither disruptive innovations imposed by management nor huge capital investment in staff or technology. It is about taking resources already available in the community – both physical and forces like compassion and goodwill – and connecting them to the people who need them.” page 13 The Compassion Project, Abel and Clarke, 2020
5.44 The work in Frome has gained deserved national recognition, and there is similar work going on in other areas of the county. For example, in south Somerset SPARK Somerset coordinates an online directory of local, low-cost activities and services giving local people access to a wealth of different groups and support services. They also coordinate village agents (paid, part-time local residents) who support vulnerable people in their communities. However, there are many neighbourhoods in Somerset where social isolation continues to be a significant driver of poor physical and mental health, and we have more work to do to connect up the many creative and effective local initiatives going on in different neighbourhoods.
5.45 We have been working hard as a county to shift our focus to prevention and undertake more activity early on in our pathways. There is a lot of good health promotion activity going on in neighbourhoods, but it is currently hard for the clinicians in our Trusts to know what relevant support is available and how to refer patients into that support, so currently they refer people back to primary care for an onward referral which creates unnecessary delay. In addition, our community rehabilitation teams often find themselves providing reactive care in response to a crisis or urgent health problem,
47 Social isolation is objectively measurable – the indicators are living alone, having few social network ties, and infrequent social contact. Loneliness is the perception of social isolation and is a subjective emotional state.
48 Loneliness and Social Isolation as Risk Factors for Mortality: A Meta-Analytic Review, Holt-Lunstad et al 49 Ibid. 50 See British Journal of General Practice, https://bjgp.org/content/68/676/e803/tab-article-info
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which takes them away from preventative rehabilitation work that helps people recover and live well.
5.46 Currently, our colleagues who are experts in medical conditions and our system partners working in enablement are poorly linked; we need to help them work better together. The role of our hospital-based clinicians needs to evolve from focusing on hospital-based work, to helping a wider pool of patients. We need to improve the sharing of our specialist advice with partners in primary care and the voluntary sector to help them help people earlier on and prevent escalation of health need.
5.47 We also need to improve the information and support we give to people to help them self-manage and ensure that at every stage we are taking steps to prevent avoidable illness and disability. As part of our county-wide frailty programme ‘Independent Lives’ we have piloted multi-disciplinary meetings where our geriatricians come together with primary care practitioners to support frail patients with complex needs. We have also begun to strengthen our wider support and advice to primary care and the voluntary sector, although Covid-19 pressures mean we have so far been unable to roll this out across the whole county.
Carers
5.48 The 2011 census found that 10 per cent of adults have an unpaid caring role, and many of them are themselves older people living with multiple long-term conditions.51 Carers are twice as likely to suffer from poor health compared to the general population, primarily due to a lack of information and support, stress and social isolation.52 Only 26 per cent of carers in Somerset aged 65 or over say they have as much social contact as they would like53, and up to 40 per cent of young carers report mental health problems arising from their experience of caring.54
5.49 Involving and supporting carers is an essential part of getting care right. Carers play a vital role in managing conditions to avoid escalation of need and flagging deterioration early to healthcare professionals. Patients who are supported by someone familiar to them who understands their needs can enhance treatment, hasten recovery and help people to stay at home. However, the strain of caring can have a negative impact on the mental and physical health of the carer. We want to listen better to carers throughout the period of care their relative receives and involve carers when we develop services, particularly as we move more services out of bed-based settings into the community.
51 NHS Long Term Plan, page 17. 52 NHS Long Term Plan, page 42. 53 https://fingertips.phe.org.uk/search/social%20contact#page/0/gid/1/pat/6/par/E12000009/ati/102/iid/90280/age/168/sex/4/cid/4/tbm/ 1 54 NHS Long Term Plan, page 43.
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Preventing the onset of avoidable disease
5.50 Our hospital estates are currently configured around bed-based care and have limited access to outside spaces which can enhance patient recovery and reduce reliance on sedating medication. Very few wards have adequate day areas – most day areas are awkward spaces, away from nursing stations, which don’t make doing the right thing the easy thing. The set-up of our wards makes spending time in bed the easy thing to do, rather than encouraging people to get up and move about if they are well enough, thus promoting independence and preventing deconditioning.
5.51 The Trusts already do some excellent work with partners on the wider determinants of health, e.g. our CAMHS work with schools, and mental health input to housing support, etc. However to have a real impact on population health we need to go further in our partnership working with other agencies.
Supporting active self-management
5.52 Some initiatives to support people to self-manage are now in place but there is more to do. While we have increased the opportunities for patients to initiate their own follow up appointments if they feel one is necessary (through Patient Initiated Follow-Ups - PIFU), we have not yet rolled this out across all our services. This means some people are still attending outpatient appointments that offer little or no clinical benefit, even though these appointments create treatment burden and fail to enhance self- management. Similarly, the assessment of patients’ ability to look after their own health, is not yet routinely occurring in all services.
5.53 While neighbourhoods are beginning to enable the promotion of active self- management, this is not consistent across the county, and the population continues to struggle with self-management with regards to many health issues such as preventable sight loss55.
Aim 1: What will change and how will merger help?
Helping people to live healthy independent lives 5.54 The core work in this aim will be done at a local level by primary care and the voluntary sector, providing tier 1 and tier 2 low level interventions which have a high impact on health (see Figure 24). The role of the merged Trust will be to support this work, which involves aligning our staffing and resources with it, providing specialist input and support, and ensuring there is mutual understanding of the range of health and care services that collectively we provide. We have already redistributed SFT’s county-wide
55 Latest Public Health England fingertips data (2018/19) show Somerset benchmarks poorly for age-related macular degeneration and glaucoma, and the trend is worsening. https://fingertips.phe.org.uk/profile/public-health-outcomes- framework/data#page/1/gid/1000044/pat/6/par/E12000009/ati/102/are/E10000027/cid/4
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district nurse teams to align with the 12 neighbourhoods, and SFT has appointed four neighbourhood development managers to support its working with neighbourhoods. Merger gives us an opportunity to strengthen these links and make them consistent across the county.
5.55 Working with our partners we will develop a programme to connect our healthcare services into neighbourhoods and communities, so that secondary healthcare professionals are able to refer people attending their clinic directly into their local neighbourhood for health and wellbeing support. Where needed, community care coordinators based in neighbourhoods will take a personalised approach to help identify the factors impacting the person’s health and wellbeing, prior to linking them to local resources that will support improvement, and drawing in complex care specialists as needed. This model is already successfully in operation in south Somerset (see Figure 41) but is patchy across the rest of the county. Across the county there are numerous and varied community health and wellbeing resources, offered by different organisations including the voluntary sector, health and social care, as well as education. Work to map these so that gaps can be identified is underway, but we expect to find gaps in provision eg in services aimed at increasing exercise and weight management, amongst others. There is scope for more input from secondary care colleagues to support these low-level but highly effective interventions such as those aimed at increasing physical activity and reducing loneliness.
5.56 We will improve our offer of support to fellow healthcare professionals to enhance their skills and knowledge and ensure referrals to secondary care are only made when clinically essential. There is good evidence that specialist advice and guidance to community healthcare practitioners at an earlier stage in an illness episode benefits both patients and services by reducing activity and costs.56 We will also increase our specialist health guidance to non-healthcare professionals in the voluntary sector to help them provide effective local support which reduces the need for people to see a healthcare professional. The enlarged workforce of the merged Trust with its broader collective range of skills would make it easier to provide advice and guidance of this sort (see Figure 26).
Figure 26: Whole system approach to healthy weight
Case study: Healthy weight Obesity is one of the biggest threats to the wellbeing of the population of Somerset, but at present there is no unifying strategy or vision for what we need to achieve. In 2018/19 more than two thirds of adults in Somerset were classified as either overweight or obese. Nearly 18 per cent of children aged 11 in Somerset are obese, and higher rates of obesity are observed in our more deprived communities. Being overweight or obese has a significant impact on health and wellbeing, increasing the risk of many physical and mental health conditions such as type 2 diabetes, hypertension and depression. Obesity is a complex problem with multiple societal and environmental factors which requires a comprehensive system response. There are many different wellbeing/weight loss/healthy activity initiatives underway in Somerset and many pockets of good practice across the health, social and voluntary sectors but they are not coordinated nor is there universal knowledge and understanding about how to access them. A ‘whole-system approach to obesity’ is an evidence-based approach that makes obesity everybody’s business. The approach takes a whole life perspective, recognising the importance of
56 Shifting the Balance of Care, Nuffield Trust, March 2017.
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Tier 1 & 2 interventions throughout childhood and adolescence. As an integrated system we want to invest primarily in wellbeing at a tier 1 and 2 level with the safety net of tier 3 and 4 services available but not the main focus. Merger will make it easier to adopt a whole system approach to Healthy Weight because there will be one fewer entities to engage with. As a single Trust it will also be easier and more efficient to free up healthcare professionals to provide the education and support to the tier 1 and 2 work that needs to happen at community level to bring this county-wide approach to life.
5.57 Health coaches play an important role in the neighbourhood model. These colleagues use a person-centred approach to help people develop confidence to manage their health conditions as well as ensuring that any liaison with other services is effective and coordinated (see Figure 27). Health Coaches can help reduce demand on services from frequent attenders or patients in crisis, and increase healthy life expectancy. However, there are currently too few Health Coaches in Somerset, and their training and competencies are not yet standardised. In addition, our healthcare colleagues do not consistently know how to access support from health coaches for their patients.
5.58 Our work with ICS partners to develop neighbourhoods includes increasing the number of Health Coaches in the county. We want to expand the Health Coach role to become fundamental to the way people are supported in Somerset as an integral part of neighbourhood teams. Our ICS aim is for the best practice in Health Coaching to be accessible to everyone in the county through a comprehensive development programme for those working in neighbourhoods, and for everyone to know how to access them.
Figure 27: Patient story Aim 1
Aim 1: James’s story
James is 63 and a military veteran. He was suffering anxiety, depression and post-traumatic stress disorder from his military experience, which led him to drink and smoke heavily. He felt suicidal but did not want to engage with his GP and refused counselling.
As part of the roll-out of Health Coaching in Somerset, James was put in contact with a Health Coach. Health coaches are hosted by the Trusts but funded by the CCG and local PCN. The Health Coach built rapport and trust with James and used a person-centred approach to understand what mattered most to him. As a result, James was able to open up about his physical health and reveal he was having difficulties in his personal life. The Coach helped James set small achievable goals which they monitored together. This approach allowed James to keep moving forward.
As a result, James became willing to engage with counselling and greatly reduced his smoking and alcohol intake. The Health Coach signposted James to services for ex-servicemen and veterans’ social groups. The Health Coach worked collaboratively with these support teams for ex- servicemen and this proved particularly valuable to James. The Health Coach also encouraged James to see his GP, which led to him being diagnosed with a prostate condition. His Coach worked through with him how he would address his abusive relationship and remove himself from the situation. The Coach also encouraged James to seek help for his housing needs, apply for Personal Independence Payment and a Blue Badge.
After working with his Health Coach James said: “I probably wouldn’t be here if I hadn’t had the support. I’ve now got the chance to turn my life around and be happy.”
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Carers 5.59 We want carers to feel supported and listened to right across the county as a vital part of the care team. Our clinical strategy is based on moving more care into home and community settings and we are committed to working in partnership with unpaid carers to understand and respond to the impact of those changes on them. We know our services need to recognise what carers need and want in three main ways:
1. Carers have their own needs around information and support.
2. Carers want to be involved in the decisions about the care of their loved one.
3. Carers want to be involved in service development, training and improvement.
5.60 The triangle of care model57 is a national initiative led by the Carers Trust which involves carers in the planning of care and treatment for individual patients. SFT uses the triangle of care model in its Mental Health and Learning disabilities directorate and community hospitals, but there is currently no consistent approach in acute settings across Somerset for supporting carers. Merger will enable us to bring together all our resources for supporting carers under one umbrella and fully embed the triangle of care approach across the county.
Data 5.61 The SIDeR programme, which brings together GP records with some of the patient data held by the acute trusts, social care and the ambulance trust was soft launched in late 2020. SIDeR helps support the prevention agenda by enabling colleagues across Somerset to see information recorded in different care settings and act early to prevent escalation of health need. SIDeR data also supports the care of people with complex needs, and the provision of care in people’s homes when it is used by community teams. Our future plans include enabling patients to link their own devices, e.g. fitness monitors, in to our records to further improve patient care.
Preventing the onset of avoidable disease 5.62 Analysis of population health data will help us identify cohorts of people who are at risk of deteriorating health. When people come to our hospitals as inpatients we want them to stay as active as possible to promote their independence and avoid deconditioning. All our wards will continue to encourage people to get up and get dressed to promote their healthiness and recovery. The estates redevelopment programmes will support this work by reconfiguring our estates and ward spaces to enhance independence and mobility. We will also develop our outside spaces, using plants and micro forests58 to create welcoming places where patients and their carers can benefit from the proven therapeutic effects of being in nature, such as reduced blood pressure59. Both Trusts’ art coordinators will work with the Estates Design Vision groups to ensure principles of therapeutic design and arts are incorporated into the planned capital works.
57 The Triangle of Care is a collaboration, or ‘therapeutic alliance’ between the service user, professional and carer that promotes safety, supports recovery and sustains well-being. 58 Developed by Japanese botanist Dr Akira Miyawaki in the 1970s, micro forests are small, fast-growing dense forests created using native species. They can be created on a tennis court-sized plot, and help people reconnect with nature, store carbon, attract wildlife, improve air quality and cut noise pollution. 59 https://pubmed.ncbi.nlm.nih.gov/28814305/
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5.63 We will also work with our partners to tackle the wider determinants of health. Complex care teams in south Somerset already work well with other agencies such as housing, the police and environmental health to get people the support they need. We will also work with the local Health and Wellbeing Board to identify areas where our financial resources and extensive specialist expertise can add value.
Supporting active self-management 5.64 We will build on the base of virtual consultations that was initiated at the start of the Covid-19 pandemic, to give time back to patients since no travel is required for these consultations. We will also extend PIFU across all our services which will empower patients and enhance self-management. Reducing travel to and from hospital sites for outpatient appointments will also help reduce our carbon footprint.
5.65 We plan to create a Rehabilitation Board consisting of senior representatives from the county’s services which will focus on helping the people of Somerset live well and recover well. This Board will oversee work to boost the support for self-management and rehabilitation across Somerset. The details of a programme we are trialling around covid-19 rehabilitation are set out at Figure 28.
Figure 28: Covid-19 rehabilitation for people with an existing long-term condition
Case study, Aim 1: Covid-19 rehabilitation Project aim
Prompted by the pandemic we are currently trialling a Covid-19 rehabilitation programme for people with a pre-existing long-term condition. The programme focuses on graded exposure to increased physical activity, lifestyle changes, and the promotion of self-management for people recently discharged from a Covid-19 ward.
Under the programme, SFT has developed a 3-month rehabilitation plan for patients referred by ward colleagues who are being discharged following treatment for covid-19. The programme informs patients about the benefits of exercise and how to safely increase their physical activity levels while managing their long-term health condition. Scheduled contact points with technical fitness instructors from the Physiotherapy department are built into each patient’s plan. These contact points provide continuing support for patients post-discharge regardless of whether or not they are able to progress their physical activity levels.
National restrictions during the pandemic mean the programme has had to operate entirely virtually. This has presented challenges in terms of designing a programme that is sufficiently engaging in the absence of face-to-face contact. However, the virtual nature of the programme has also forced patients to take an active role in their rehabilitation rather than relying on clinical contact, and this helps promote self-management.
We are collecting outcome measures which will indicate whether or not there is objective improvement for patients in terms of function, confidence in taking physical activity, and mental wellbeing.
If the programme proves successful we will expand it across Somerset so it becomes an integral part of our work to support people whose health needs require them to improve their levels of physical activity. Our ultimate aim is to have a tiered package of support, provided in partnership with neighbourhoods, to help people with long-term health needs increase their physical activity. At the appropriate point the aim would be to transition people from the programme to non-health services e.g. local gym support referral schemes.
The programme serves as proof of concept for possible future programmes which help people with one or more co-morbidities and who are limited by a fatigue-related condition.
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5.66 Our joint work to introduce webinars for gastroenterological conditions and online support for people to self-manage their diabetes demonstrates the benefits of tools to help patients self-manage, see Figure 29. We also know the introduction of patient education in the community Orthopaedic Assessment Service boosted self- management, resulted in fewer patients who ‘Did Not Attend’ and led to fewer referrals into the spinal service which improved (Referral to Treatment) RTT performance. We will extend to other services the provision of support and education to aid self- management.
Figure 29: MyWay Diabetes
Case study: MyWay Diabetes MyWay Diabetes60 is an online diabetes platform which supports self-management. 34,000 people in Somerset have diabetes and the service is available to anyone registered with a Somerset GP. It was made available in Somerset four years ago following a successful joint bid from YDH, SFT, Somerset CCG and primary care. The platform provides access to resources for people with diabetes or ‘pre-diabetes’, and their families and carers. People with diabetes can register securely on the site and then access their own diabetes-related data drawn from EMIS. The site helps people set personalised goals and gives personalised links to relevant resources. Regular users have shown improvements in blood sugar control, blood pressure and cholesterol. The service has received very positive patient feedback and is highly cost effective at only £2 per patient per year.
Aim 1: Benefits
5.67 The anticipated benefits from this aim include:
Improved health outcomes from earlier intervention Better support for carers and their families to help them continue to play their critical role in promoting health and wellbeing Reduced pressure on our services and our partners’ services: primary and social care, and the voluntary sector; and Improved ability to meet rising demand within our existing resources
Aim 2: Ensure safe, sustainable, effective, high quality, person-centred support in the most appropriate setting
5.68 The intention of this aim is to get the fundamentals of care right and put the people we serve at the heart of their care.
60 https://somerset.mydiabetes.com/
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Aim 2: What’s the problem?
Patient pathways 5.69 As part of the creation of SFT, a programme of work was established to improve patient pathways as some patients do not experience joined-up care, and some pathways are confusing and hard to navigate. Some improvements have been made as part of this work, although progress has been hampered by the pandemic.
5.70 There are differences between the secondary care elements of many pathways delivered by the two acute hospitals. For example, although the community element of the leg ulcer service is delivered by a single county-wide team, the acute element of the pathway is different at Yeovil hospital and Musgrove Park hospital. In some cases these differences include different treatments, diagnostics and waiting times, and this means people in different parts of the county receive different care. There are also inconsistencies in referral criteria, onward referrals for the same medical problem, and different approaches to patient correspondence.
Care in the right place 5.71 There is more we can do to value our patients’ time with respect to them staying overnight in hospital. Most of our patients are older, and these are the people for whom time is most precious. Despite recent changes to the mental health model to enhance community-based care, we continue to admit some people to hospital beds both in acute and community hospital settings who could be cared for in their own homes if the right level of personal care were available.
5.72 While our delayed transfers of care programme has been hugely successful in helping people leave hospital in a timely way, pre-discharge care differs between the two acute sites. This means people across the county are receiving different care and our Discharge to Assess service is working with two different approaches.
5.73 Our advance care planning programme, known as the ‘Last 1,000 days’ is now well established and includes our county-wide treatment escalation plan (STEP). The aim of the programme is to maximise the time people have at the end of life to do what matters to them most. It aims to prevent harm from overtreatment, especially in hospital settings, which can be a particular hazard for frail or cognitively impaired people. 61 The introduction of this programme three years ago has been a major step forward, but we need to deliver further training to get advanced care planning conversations and documentation right and ensure we understand patients’ wishes and do not over-treat.
Patient information 5.74 The information we provide about individual conditions and treatments across our Trusts is patchy and inconsistent and leads to people lacking key knowledge about their illness and how to best manage it. Many people still associate a hospital stay with getting the best care even though it may not be most appropriate for their care needs and carries the risk of hospital-acquired harms.
61 Our last 1,000 days programme is based on the national programme launched by Professor Brian Dolan and Linda Holt.
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Medicines optimisation 5.75 Medicines optimisation is a person‑centred approach which uses shared-decision making to ensure people obtain the best possible outcomes from safe and effective use of medicines. Medicines optimisation applies equally to patients who may take their medicines effectively (good ‘compliance’ or ‘adherence’) and to those who don’t (poor ‘concordance’). Ten days after starting a medicine, almost a third of patients become non-adherent either inadvertently (55 per cent) or intentionally (45 per cent). About 6 per cent of unscheduled admissions are believed to be attributable to adverse effects of medicines.
5.76 In the decade to 2013, the average number of prescription items per person per year in England increased from 13 to 1962. As a population ages, co-morbidities increase and so too does the use of multiple medicines (‘polypharmacy’). Polypharmacy may be appropriate to achieve the desired benefits and outcomes but can lead to negative outcomes or poor treatment effectiveness (‘problematic polypharmacy’). Problematic polypharmacy is associated with higher healthcare costs and has adverse effects for patients, particularly older people63 including adverse drug reaction, reduced function, impaired cognitive capacity and increased risk of falls. Addressing problems caused by problematic polypharmacy is a key part of Medicines Optimisation. We have already begun a de-prescribing project in mental health, and plan to extend this to both acute and community hospitals.
Continuous improvement in clinical practice 5.77 Finally, each Trust currently has its own system for learning from incidents and excellence. These systems are currently disconnected, which hampers the sharing of learning across the county between the Trusts, primary care and social care.
Aim 2: What will change and how will merger help?
Patient pathways 5.78 We will ‘make pathways everybody’s business’, which means colleagues in all the organisations in our ICS will take responsibility for the effective end-to-end operation of patient pathways, rather than just the part of the pathway they are directly involved with.64 This means, for example, that acute clinicians will play their part in supporting primary care and the voluntary sector to prevent ill health and support wellbeing, rather than just treating people once they have become ill. Every clinical service in the merged Trust will become a single county-wide service, with a single set of pathways which will make this task much simpler, see Figure 30.
62 https://digital.nhs.uk/data-and-information/publications/statistical/prescriptions-dispensed-in-the-community/prescriptions- dispensed-in-the-community-statistics-for-england-2003-2013 In England, over 1.03 billion items were prescribed in 2013 compared to 649.7 million in 2003. Population of England in 2003: 49.93 million; population in 2013: 53.87 million. 63 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3864987/pdf/nihms-484047.pdf
64 We recognise that patients with complex co-morbidities may need more than a standard pathway and for these patients we will coordinate care in a bespoke way, see Aim 5.
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Figure 30: Stroke services
Case study: Stroke services Our vision for Stroke services is a single county-wide team with a hyper acute stroke unit on one site (Taunton), acute services at both Yeovil and Taunton, community rehabilitation units at Williton and South Petherton community hospitals and integrated community services supporting patients at home. These will be supported by an integrated stroke research team.
YDH has struggled for many years to recruit a second substantive stroke consultant which has made it difficult to provide timely specialist medical assessment and care, including specialist ward rounds, 7 days a week. Merger offers the opportunity for relevant patients to be directed to just one site in the county, which will be easier to staff 24/7 and make the service safer. Merger would increase team resilience and make it easier to cover staff shortfalls. It would also offer increased opportunities for professional development and enable us to make a more attractive offer to potential recruits to the stroke team.
5.79 We know that improved communication between clinicians within a pathway supports swifter and more effective patient care. For example, multi-disciplinary virtual Diabetes team meetings have reduced unnecessary referrals into secondary care, see Figure 31. Merger will make it easier to support greater communication between our colleagues and other clinicians and care professionals in Somerset.
Figure 31: Making pathways everybody’s business – diabetes service
Case study: diabetes service Age is a major factor in developing Type 2 diabetes, and Somerset’s population is older than the national average. If we do nothing we expect the incidence of diabetes in the county to rise to 53,000 by 2030. Most cases of Type 2 diabetes are managed by primary care but GPs have been struggling to cope with the rising demand and a lack of knowledge about how to manage more complex patients and the large number of new medications. In the last two years SFT and YDH teams, in conjunction with the CCG and GPs, have implemented a series of projects to transform services and provide a single county-wide diabetes service. Multi-disciplinary team virtual clinics in GPs practices bring together colleagues from primary, intermediate and secondary care – specifically a Diabetes Consultant, Nurse Consultant in Diabetes, Diabetes Specialist Nurses, health coaches, GPs and Practice nurses to discuss complex diabetes patients. Relevant patient information is available and questions about the treatment regime and management are discussed. Best practice is shared and, through peer education, colleagues increase their understanding of how to manage complex patients. In between the MDT virtual clinics, practices are supported by the intermediate care consultant nurse / specialist nurse team, who carry out further virtual clinics with practice nurses to support the implementation of the agreed management plans and follow up any issues. This work led to a reduction in the need for face-to-face specialist referrals. 97 per cent of practice staff felt more able to support people with diabetes. These changes provide quicker and easier access to a specialist opinion, lead to fewer face-to-face appointments with patients, and GP practices are better able to support diabetes patients within the practice rather than referring onwards to secondary care.
The Diabetes service has also introduced District nurse MDT virtual ‘ward rounds’ in which Diabetes specialist nurses/nurse consultants review the District Nursing caseload with district nursing teams to ensure patients are on the right medication and their capacity to self-manage is maximised.
5.80 We will develop the programme which has started in SFT to integrate, streamline and standardise patient pathways spanning community, mental health and acute services to remove duplication, and support seamless care. We will spread this work across the
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county to all the services currently provided by the two Trusts. We will review and redesign pathways from the patient perspective and ensure care is focused on what matters to them.
5.81 We know from work done on the leg ulcer pathway that there is scope to significantly reduce the number of steps that patients go through on some pathways, and thereby improve patient care and experience. Bringing together the community and acute parts of pathways also makes it easier for more complex patients to be identified and treated at an earlier stage, and for a shared and integrated workforce to offer more targeted support to patients. The case study on Complex Care Teams in south Somerset (see Figure 41) is a excellent example of a model of intense care for complex patients by a multi-disciplinary team. Merger would make spreading this model across the county far easier.
5.82 We will ensure pathways cover early symptoms through to acute and inpatient settings; pathways will be based on initial presenting symptoms rather than disorders or disease. There will be specialist review early in the pathway to aid early intervention and prevent escalation of need. We will work with primary and social care and the voluntary sector to plan and implement these pathway changes. Implementing these changes will be more straightforward as a merged Trust.
5.83 Pathways and how to access them will be clear to patients and colleagues alike. We will also streamline referrals between specialists to cut the incidence of complications and patient complaints that arise from delays in referrals between services.
5.84 We will remove procedures which are of limited diagnostic value. The Trusts are already working with their partners to reduce the number of lumbar spine x-rays by implementing standardised referral criteria across the county, and ensuring patients are referred to appropriate pathways for the management of low back pain.
5.85 Although this pathway work could be done while we are two separate organisations, in practice it will be much easier if we are one Trust, since the barriers to collaboration arising from separate budgets, line management structures, governance arrangements and so on, would be removed.
5.86 Merger will help us implement the recommendations of the recent Ockenden review into maternity services. Currently the scope for the Trusts to fully comply with the immediate and essential actions set out in the Ockenden review is limited by workforce and financial constraints. Pooling our resources would remove barriers and offer economies of scale which put us in a better position to implement the recommendations. Creating a single Somerset maternity service will enable us to agree a single set of pathways, ensure equity across the county and create a more efficient and effective service.
Care in the right place 5.87 We want to make sure patients are seen by the right clinician and only have a face-to- face appointment when one is clinically required. We will deliver care in the least intensive, most appropriate setting (e.g. at home, or in a community setting). We will take a ‘digital first’ approach to patient contacts, with care occurring virtually where possible - either via telephone or skype consultation, and pathways will include patient
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activation mechanisms such as PIFU. This will be more convenient for patients, reduce cost, and free up clinical time to help reduce waiting lists and manage rising demand.
5.88 We will develop same day emergency care (SDEC) as the default option for emergency care at both the acute hospital sites. This will sit alongside day surgery, and would mean that, where clinically appropriate, we will treat patients on the same day and support them to return home that day. Our provision of same day emergency care has been increasing over time, but further development of this service at our acute sites will support patient independence and reduce avoidable illness and harm.
5.89 Intermediate care services are key to the effective provision of SDEC by getting people home at the end of the day with the support in place to help them recover. We will put in place consistent SDEC pre-discharge pathways to help intermediate care do their job. Although consistent SDEC pre-discharge pathways could be put in place at both organisations, merger would make it easier because separate line management arrangements and budgets (which can be a barrier to collaboration) would be removed. Merger will also solidify the work underway to bring together the east and west Discharge to Assess services (see Figure 33).
5.90 Merging SFT and YDH will allow us to enhance the reach and ease of implementation of the Last 1,000 days programme and give it single leadership. We will enhance our advanced care planning and treatment escalation documentation, and extend this approach to patients who are being considered for treatment in our intensive care units. Having the right conversations with patients and their families/carers will make sure they receive the treatment and care that is right for them.
Patient information 5.91 We will provide standardised information to patients and carers about individual medical conditions and possible treatments, to ensure people can make informed decisions about their own care, and make this accessible to everyone who needs it. We will increase transparency about hospital-acquired harms and tackle the popular misconception that hospital is always the best place to receive care. We will promote the message that ‘your bed is best’ and encourage patients and their families to consider what is most appropriate for their stage of life and health.
5.92 We will store patient information in a way that can be readily accessed by colleagues involved in their care, to avoid repeat clinical assessments and frequent changes in care regime. We will implement an IT solution across the merged Trust which enables all relevant healthcare professionals to easily see the records of patients they are treating, thereby removing the need for people to repeat their story and enabling safer, more efficient care. This will be supported by a single colleague sign-on to our IT systems.
5.93 We will put in place consistent administrative processes (including standardised patient communications which clearly explain what is happening) and which support good patient experience.
Medicines optimisation 5.94 We want to work with patients and carers to improve the patient experience in relation to medication and support people to use medication effectively to optimise their health
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and resilience (Medicines Optimisation). We will facilitate ‘responsible prescribing’ to address the problems of polypharmacy and overprescribing, and minimise medicines- related harm. We will also embed self-management of medication (with clinical supervision if required) in acute, mental health and community health services.
5.95 Implementation of effective population-wide Medicines Optimisation requires effective working and communication across the healthcare system. Removal of organisational boundaries through merger would remove many of the obstacles to effective system working and thus facilitate efficient medicines optimisation. For example, effective transfer of care including around medicines (TCAM) would be facilitated by merger, and the use of a single electronic record and electronic prescribing and medicines administration (EPMA) system across the merged organisation will enable a ‘do once’ approach as the patient moves through pathways (e.g. medicines reconciliation). This will free up healthcare workforce time to concentrate on other aspects of care such as Medicines Optimisation.
5.96 Pharmacists and Pharmacy Technicians as the medicines experts have a key role in medicines optimisation as part of the multi-disciplinary team, and by supporting prescribers (medical and non-medical) in making prescribing decisions to achieve better patient-orientated outcomes. Merger will free up resources for example by removing the need for duplicate MHRA65 and Home Office licences for medicines supply, reducing wastage of medicines through efficient recycling where appropriate, and the adoption of a ‘do once’ approach which allows re-deployment of our combined resources.
Continuous improvement in clinical practice 5.97 Data-driven decision-making is core to our quality improvement approach. We will ensure colleagues have access to the data and evidence that helps them plan changes that are evidence-based and to evaluate clinical outcomes. Bringing together our two Improvement teams will give us greater capacity to train our colleagues in quality improvement methodology so they are able, with the necessary support, to design and implement transformation in their services (see Chapter 6).
5.98 All healthcare interventions will be based on the best available evidence which we will support through high quality colleague training and support. Our combined library services will support colleagues to ensure they have access to the latest research findings to inform their clinical practice and transformation planning.
5.99 Finally, merger would help address the barriers to learning from incidents and excellence, by moving us closer to our ultimate aim of having one system across all health and social care settings for gathering and sharing learning.
65 Medicines and healthcare products regulatory agency.
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Aim 2: Benefits
5.100 The anticipated benefits from this aim include:
improved health outcomes from earlier intervention on streamlined pathways improved patient and carer experience from pathways that are easier to navigate increased colleague satisfaction from simpler, more efficient pathways and more targeted use of their skills reduced pressure on our services and our partners’ services: primary and social care, and the voluntary sector improved end of life care which supports individuals to make the most of their time improved ability to meet rising demand within our existing resources better data and information for learning and planning.
Aim 3: Provide support in neighbourhood areas with an emphasis on self- management and prevention
5.101 Working in collaboration with our partners in primary and social care and the voluntary sector, the purpose of this aim is to provide more care in local communities, closer to people’s homes, where it is clinically appropriate and cost effective to do so, and bearing in mind patient and environmental considerations.
5.102 The continued development of the 12 neighbourhoods in Somerset, using a county- wide consistent approach which allows adaptation to local needs, is at the heart of this aim. Somerset’s neighbourhood teams provide health care and support in local areas, breaking down the concepts of primary and secondary care, and offering support that is strengths-based and focused on prevention and early intervention in line with the NHS Long Term Plan.
5.103 As a system, we want to provide care at the lowest level appropriate, starting with self-management and only escalating through increasing levels of support if the person’s health needs require it (see Figure 24). Our neighbourhoods will offer easy access to advice on staying well, a range of preventative services – including those that support social connectedness – and simple, joined-up care and treatment close to people’s homes. Services will be tailored to the needs of the local community, and accessible through both digital and non-digital routes to prevent exclusion of people without online access. We intend to use a model of self-referral wherever possible. The services offered at neighbourhood level focus mostly on tiers 1 and 2 but will also play a role in care at tiers 3 and 4 (see Figure 24).
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Aim 3: What’s the problem?
5.104 Somerset has struggled in recent years with insufficient community services to support some patients at home (and their families/carers) when they become ill or their needs increase. Some people who are unable to look after themselves in the normal way at home have been admitted to hospital - not because their needs require bed-based care but because there were no other options available locally to help them manage at home when they were unwell or becoming frail. Unnecessary bed-based care exposes patients to the risk of hospital-related harm, is inconvenient for patients and carers who have to travel a long distance to hospital, and incurs cost for the system that could be spent elsewhere.
5.105 Twenty per cent of pensioners who attend an NHS outpatient appointment say they feel worse afterwards because of the stress involved in the journey alone.66According to the Sustainable Development Unit,67 NHS-related traffic accounts for 5 per cent of all road traffic in England, and this traffic is responsible for 13 per cent of the NHS’s carbon footprint.68 69 Our care delivery needs to factor in the hidden costs of healthcare including environmental impact and patient anxiety, as well as the costs incurred by patients for missed work, additional childcare, travel costs etc.
5.106 Together with our partners we have been developing our 12 Somerset neighbourhoods over the last three years. Each neighbourhood brings together colleagues from across the county’s health and social care workforce to support people close to home.
5.107 Neighbourhood teams comprise a wide range of colleagues drawn from YDH, SFT, Somerset County Council, primary care and the voluntary sector. These include District Nurses, Social Workers, Older People’s Mental Health specialists, Occupational Therapists, Community Midwives, Community Paediatricians, Health Coaches, Health Visitors, Care Coordinators, MSK First Contact Practitioners and more. Examples of current activity in neighbourhoods is set out in Figure 32.
Figure 32: Current neighbourhood offer
The following programmes are currently underway in our neighbourhoods: Intermediate Care service provides short-term stabilisation, assessment, and reablement support aimed at maximising a person’s independence and where possible, helping people to remain in their own home. This care is given to people in the community who would need acute care unless intermediate health intervention is provided (diversion), or to those who are medically optimised following an episode of acute care (supported discharge). This care includes provision for people whose primary need is short-term care and comfort at the end of their life, and thereby supports our ‘Independent Lives’ programme aimed at helping frail older people live as they wish, giving them time to do what is important to them.
66 Outpatients: The Future, Adding value through sustainability, Royal College of Physicians, 2018 67 The Sustainable Development Unit is funded by NHS England and Public Health England. 68 www.sduhealth.org.uk/areas-of-focus/carbon-hotspots/travel.aspx 69 NHS road traffic is associated with 85 deaths and 722 major injuries a year. Source: Outpatients: The Future, Adding value through sustainability, Royal College of Physicians, 2018.
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Open mental health: this programme takes an ‘open to everyone’ approach to mental health and wellbeing support within neighbourhoods with a focus on preventative engagement. Everyone who wants help is given support tailored to their needs by a range of voluntary sector and health professionals. MSK First Contact Practitioner programme: an estimated 30 per cent of primary care consultations are related to musculoskeletal (MSK) conditions, and Somerset ranks worse than benchmark for people reporting a long-term MSK problem70. This programme has introduced advanced MSK physiotherapists who work alongside GPs and act as the first point of contact for patients with MSK conditions. Falls prevention: this programme aims to establish a comprehensive service to prevent falls and thus admission to hospital. It includes trusted assessment, personalised care plans to reduce risk of falling and social prescribing of balance and strengthening exercises Diabetes support: nurse-led multi-disciplinary team meetings to improve insulin administration for housebound patients.
5.108 The operation of different neighbourhoods in Somerset varies, and processes and protocols are inconsistent. There are individuals working in different neighbourhoods with similar roles but different job titles. Secondary care colleagues from the two Trusts support neighbourhoods by providing specialist advice and participating in multi-disciplinary teams and rapid access clinics. However, the two Trusts’ teams currently work under different contracts, managers, clinical leadership and processes. Although this does not prevent them supporting neighbourhoods it does make it more difficult, in part because neighbourhood staff have to deal with two different approaches. For example, although the strength of Somerset’s Intermediate Care service is nationally recognised, the service would be further enhanced by a consistent approach from both acute hospitals, see Figure 33.
Figure 33: Colleague perspective on Discharge to Assess service
Colleague perspective: Tamsin Carey, Manager Somerset Discharge to Assess service The YDH and SFT Discharge to Assess services came together during the first wave of the pandemic to form a county-wide Discharge to Assess service. When the services were separate neither had a county-wide view of need, so could not effectively prioritise demands.
Once the teams combined they agreed a shared vision and standardised the links between health and social care. Their Somerset-wide view of demand and capacity now enables equity of provision and aids flow from the acute and community hospitals. Pooling resources, joint problem solving and sharing knowledge and experience has helped create a better service that draws on the best of both legacy teams. Previously both teams struggled with recruitment and retention but working together they have focused on team culture and wellbeing and have improved their staffing position.
Despite these improvements, the team has to work around challenges created by the fact that members of the team have different employers. This causes difficulties with day-to-day operations including managing rotas and sickness absence, training, IT provision and storage of information. Merger would remove these challenges and make it easier to support colleagues and run the service.
“We were previously working in parallel services. Trying to do the best for our patients, with the same remit, but quite different models and two small voices. Joining together into a single team has enabled us to bring all the passion and drive for this service into a more
70 Public health England Fingertips data https://fingertips.phe.org.uk/profile/public-health-outcomes- framework/data#page/1/gid/1000042/pat/6/par/E12000009/ati/102/are/E10000027/cid/4
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powerful, focused voice and vision. Using the skills and knowledge across the east and west has enabled the creation of a sustainable model. We’ve been able to focus on staff wellbeing, patient experience and use Quality Improvement methodology to build the service. It’s exciting to think how we can develop further with a possible merger.”
5.109 As we move through the tiers of support (see Figure 24), there is also scope to develop our offer at neighbourhood level. For example, there is good evidence that earlier intervention to ensure patients are optimised for surgery - peri-operative care - leads to improved health outcomes, see Figure 34.
Figure 34: Peri-operative care
Case study: Peri-operative care We plan to develop peri-operative care at neighbourhood level by bringing together acute clinicians, pre-operative assessment services, neighbourhood health and wellbeing services, and primary care. Following a GP consultation, for hip or knee pain for example, this programme will optimise patients for surgery and give them the best chance of benefitting from the intervention. This will include triaging them for surgical risk, ensuring they are fully informed about the risks posed by the potential operation, and developing a personalised plan to optimise their health in preparation for surgery. The patient will see the surgical team once their health is good enough for surgery to be of benefit. SFT is currently setting out a test and learn project for patients referred from the orthopaedic service (OASIS) for elective hip and knee replacements. At the same time YDH and SFT are working with system partners to develop the plan ready for scaling and spreading this model using improvement methodology.
Aim 3: What will change and how will merger help?
5.110 Merger would support the ‘flexible standardisation’ of neighbourhood operation across the county – bringing a consistent framework but retaining the scope to modify the operation and focus of individual neighbourhoods according to local needs. The governance of neighbourhoods and the supporting infrastructure has still to be developed and agreed. Merger would reduce the number of stakeholders and simplify interactions between neighbourhoods and secondary care, thereby freeing up colleagues to devote more time to frontline care.
5.111 The Open Mental Health programme began in 2019 and further integration into neighbourhoods is still needed to ensure all those who might benefit are able to access it. YDH is not currently part of the programme (as it does not provide mental health services), but merger would make it easier for mental health service users in south Somerset to access physical health support.
5.112 Merger would reduce barriers, support closer working relationships, and drive consistent support from secondary care to neighbourhoods. Bringing our secondary care teams together also enables us to pool our resources and frees them up to give better support to neighbourhood teams, see Figure 35.
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Figure 35: Patient story, Aim 3
Aim 3: Frank’s story
Frank was active well into his 90s, using an exercise bike to keep fit, and continuing to live independently. Aged 99, Frank was admitted to MPH with breathing difficulties. While in hospital he became disorientated in the unfamiliar surroundings and fell twice, first breaking his thighbone and then later his hip. Following a month of rehabilitation he was discharged home, but by then he had lost his independence. Unfortunately, Frank needed to be readmitted to hospital shortly afterwards, and he died at MPH shortly after his 100th birthday.
What will change Frank’s condition did not require admission to hospital. We want to get our community care right so that people can be better supported to stay at home and avoid the harm that can occur in hospital especially to older people. This will involve specialist advice from geriatricians to neighbourhood teams so that people like Frank can be given care and support in their own home. We are already delivering services that enable people to receive care at home (and this has accelerated under the pandemic) but we need to build further on this to avoid the need for an acute stay and the associated risk of harm from deconditioning which can reduce independence, especially in older people.
How merger will help Merger will allow us to pool the resources of our two geriatrics teams, and to fully link up YDH’s acute services with community services currently managed by SFT so that we can better care for people like Frank.
Aim 3: Benefits
5.113 The anticipated benefits from this aim include:
better patient health outcomes from earlier intervention eg improved peri- operative care patients supported to stay well in their own home to preserve independence improved patient and carer experience - lower anxiety and greater convenience from not having to travel so far to receive care and having their time valued improved Trust ability to meet rising demand within existing resources by curbing inappropriate admissions to hospital thereby reducing financial pressure on the system and boosting our performance against national standards more engaged and motivated workforce from providing improved care more resilient communities able to generate their own high quality, cost effective and sustainable local solutions to support wellbeing empowered and confident partners in primary care and voluntary sector, working with us to achieve our shared vision for the county.
Aim 4: Value all people alike and give equal priority to physical and mental health
5.114 This aim seeks to address health inequalities and ensure there is equity of care across the county. This aim has the highest priority in our clinical strategy, see Figure 36.
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Figure 36: Mahatma Gandhi quote
“The true measure of any society can be found in how it treats its most vulnerable members” Mahatma Gandhi
Aim 4: What’s the problem?
5.115 Health inequalities are largely preventable. There is a clear moral case for addressing them, as well a strong economic case. The annual cost of health inequalities is estimated to generate £12.5 billion in additional costs for the NHS and lead to £20-32 billion in lost taxes and welfare payments.71
5.116 Public Health England has identified four dimensions for assessing health inequalities72, see Figure 37. Age, sex and hereditary factors feature, as do social- economic and environmental factors.
Figure 37: Dimensions for assessing health inequalities
5.117 There is a lack of standardisation across Somerset, with different patient pathways operating in different areas of the county, and different offers from the two acute hospitals which creates inequities in care. Currently there are separate waiting lists
71 https://www.health.org.uk/publications/reports/the-marmot-review-10-years-on 72 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/730917/local_action_on_health_ine qualities.pdf
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for many services so some patients wait longer than others in the county for treatment.
5.118 Like the rest of the NHS, our Trusts regularly struggle to meet elective demand in the winter months, meaning people who present at this time of year frequently have their planned care delayed because of winter pressures.
5.119 In the SFT clinical strategy, we noted that the life expectancy of women in Somerset with a mental health disorder is 17.5 years lower than for women without serious mental illness; for men in Somerset the difference is 19.7 years. This discrepancy is replicated around the country and is attributed mainly to cardiovascular disease and cancer, rather than the underlying mental health condition.
5.120 Patients in Somerset with dual diagnosis (mental health problems and substance misuse) currently have problems accessing good care and support (both physical and mental health). The care in Somerset for this group of people has historically been fragmented as a result of commissioning decisions made many years ago. People have to navigate a variety of discrete services including addiction services, mental health, primary care and acute services, as well as voluntary sector support and other public sector provision such as housing. As a result, the care and support to people with dual diagnosis is often disconnected and can lead to poorer health outcomes than for other groups.
5.121 Health inequalities also exist for people with disabilities. For example, people with cognitive difficulties such as learning disabilities and dementia can find our estates difficult to navigate, and our patient pathways hard to understand.
5.122 Covid-19 has given greater prominence to health inequalities experienced by Black Asian and other minority ethnic groups, in particular the health of our own NHS colleagues. Hospital Episode Statistics data indicate that Black people have higher rates of myeloma and stomach cancer, and Black men have higher rates of prostate cancer than White men.73 Analysis of census data shows that ethnic health inequalities are most pronounced at older ages.74
5.123 Biological sex impacts health: mortality rates are higher for men than women for all the major causes of death including cancers and cardiovascular disease. However, women have much higher rates of disability than men, especially at older ages and more morbidity from poor mental health, particularly related to anxiety and depressive disorder.7576 There are sex differences in how males and females respond to many drugs, and present with disease such as cardiovascular disease and autoimmune
73https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/730917/local_action_on_health_in equalities.pdf 74 Ibid. 75 https://www.healthknowledge.org.uk/public-health-textbook/medical-sociology-policy-economics/4c-equality-equity- policy/inequalities-distribution 76 The World Health Organisation suggests that sex differences in health are a result of biology as well as the distinct roles and behaviours men and women adopt as a result of cultural gender norms. https://www.who.int/social_determinants/resources/csdh_media/wgekn_final_report_07.pdf
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dysfunction. However, research often generalises findings on males to females,77 and diagnosis and healthcare provision often fails to take sex differences into account.
5.124 Further data on health inequalities in Somerset is contained in Appendix 2.
Aim 4: What will change and how will merger help?
5.125 We are committed to reducing health inequalities through services that are designed and delivered to improve people's lives and ensure fairer life chances for all.
5.126 Our initial focus under this aim will be around improving equity of access to care, and addressing those health inequalities for which we already have data eg the shorter life expectancy for those with a mental health disorder. However, we recognise that significant data gaps exist, and we are committed to working with our partners in public health to better understand local health inequalities. Population health analytics has a powerful role to play in helping us identify where and what health inequalities exist in Somerset, and our capacity to do this work will be much improved by merger.
5.127 Merging the two Trusts will facilitate our planned work around equity by helping to drive standardisation of approach and remove unwarranted variation. Every clinical service in the merged Trust will become a single county-wide service, with a single management structure, set of pathways and a single waiting list. Services will operate to consistent standards right across the county. This work to combine services has already begun in some areas including urology, palliative care and oncology.
5.128 Co-production with the people that use our services is fundamental to tackling health inequalities; we will listen to the people who use our services and work with them to address the concerns they raise. We will also work closely with partner organisations, both statutory and voluntary, to design and deliver integrated services.
5.129 As noted above (paragraphs 5.102-5.103), the provision of care in neighbourhoods will be tailored to the needs of the local population, which will help tackle health inequalities. Development of our neighbourhood provision will also bring more care closer to where people live which will help address the access challenges presented by geography. The increased use of virtual consultations will also improve access by removing the need to travel for some elements of care.
5.130 By moving more care into neighbourhoods we will free up some acute capacity which will enable us to continue with more elective care during the winter, thereby contributing to addressing seasonal inequities in care.
5.131 As a combined acute, community and mental health trust, SFT has been able to improve the physical healthcare given to people with mental health problems, and
77 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3008499/ Biomedical research often makes the assumption that results from males apply to females, or females are excluded due to concern that female hormonal cycles decrease the homogeneity of study populations and confound the effects of experimental manipulations.
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also improve the mental health support given to people with physical illness by bringing together clinicians from physical and mental healthcare services. By merging YDH and SFT we will be able to extend this model right across the county and ensure it is reflected in all the care settings run by the merged Trust, thereby moving towards our aim of putting mental health on a par with physical health78, see Figure 38.
Figure 38: Patient story, aim 4
Aim 4: John’s story
John is 38 and lives in a care home. He has severe learning disabilities (LD) and epilepsy. John was admitted to hospital with a chesty cough, shortness of breath and a poor urine output and was thought to have aspiration pneumonia.
John’s health passport detailed his eating and drinking requirements, designed to reduce his risk of choking. However, this plan was not followed and John was given a normal diet which could have resulted in harm. In other cases we know that some patients have been put on nil by mouth when colleagues have been unsure whether to continue with their eating and drinking plan set out in the health passport. High turnover of acute staff, and the relatively low number of people with learning disabilities admitted to hospital (especially for unplanned care), means people with LD sometimes receive poorer care because colleagues lack confidence in how to care for this group of patients. This issue has been recognised as a national problem following the tragic death of Oliver McGowan.
What will change To improve patient care and experience and reduce risk of harm, our LD specialists have begun training colleagues to build their knowledge, skills and confidence in caring for inpatients with learning disabilities. This will build on the principles of trusted assessment and informed positive risk-taking. We are also working with Somerset CCG to improve annual health checks and care plans for people with learning disabilities.
How merger will help Merger will enable us to adopt the same ethos and approach to the care of patients with learning disabilities (LD) across all inpatient settings in the county and ensure that all inpatients with LD receive high quality care tailored to their needs. This work will support implementation of the Oliver McGowan Mandatory Training in LD and Autism.
5.132 Prior to the pandemic, we began implementing our county-wide ‘Stolen Years’ programme which aims to increase the life expectancy of people with mental health problems by improving their physical health. This programme will span all the tiers of care (see Figure 24), from, for example, Open Mental Health in neighbourhoods (see Figure 32), through to support for people with a mental disorder when they are in hospital. The latter will include helping people cope with their inpatient stay and ensure they get care for their mental illness while they are in hospital. Unfortunately progress on this programme has been hampered by the pandemic, and there is more to do to secure the impact we are aiming for.
5.133 The bringing together of our paediatric and CAMHS services into county-wide services will improve the focus on children in Somerset, which has historically been a cause for concern, especially regarding children with mental health problems. The
78 Also known as ‘parity of esteem’.
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rise in mental health problems in children during the pandemic means this work has never been more important, and we are determined to use the merger to provide better care for children from local neighbourhood care right through to inpatient provision. We will also strengthen our relationships with partners to take forward work on the Special Educational Needs and Disabilities (SEND) agenda.
5.134 Good dual diagnosis work has started in Somerset, but this programme of work requires effective input from multiple organisations to succeed. For our part, merger would allow us to bring single senior leadership and strengthened engagement to this work which will help improve the health outcomes, experiences, and life expectancy of this vulnerable group.
5.135 We are also exploring the possibility of an outreach nursing service for homeless people and care leavers aged 16-25 (who are at high risk of homelessness) to provide them with targeted, accessible mental and physical healthcare services. If the service proves effective, we will use it as a template for services for other vulnerable patient groups such sex workers, refugees, and travellers.
5.136 Our Estates design principles include the commitment to ensuring our estates support people with complex needs including those with dementia, learning difficulties and other forms of disability (see Appendix 9).
5.137 Alongside our healthcare provision, the merged Trust will also be a significant local employer providing attractive jobs and apprenticeships with good career prospects. This is an additional way in which we will contribute to addressing inequalities based on socio-economic differences.
Aim 4: Benefits
5.138 The anticipated benefits from this aim include:
improved equity of access to care across the county improved physical health outcomes for people with mental health illness; less escalation of care need for people with mental health issues - which aids our ability to meet rising demand within existing resources; better care for marginalised groups including people with dual diagnosis and those who are homeless; improved experience of patients with mental health illness; and reduction in socio-economic health inequalities, and inequalities based on protected characteristics.
Aim 5: Improve outcomes for people through personalised, co-ordinated support
5.139 This aim seeks to improve the care and experience of people through improved coordination and personalised care. It covers the whole population although the main
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weight of effort will be directed at those with complex care needs or people living with more than one long-term condition, who spend the most time in healthcare.
Aim 5: What’s the problem?
5.140 The needs of the people we care for are changing. People are living for longer with more complex health and care needs. By 2035, two-thirds of adults in England are expected to be living with multiple health conditions, and 17 per cent will have four or more conditions.79 In Somerset 4 per cent of patients account for 50 per cent of all health expenditure.80
5.141 Patients with complex needs often require personalised, coordinated care. However, coordinating care remains a challenge in most healthcare settings. Healthcare pathways tend to develop around one disorder, and many colleagues are trained in distinct specialties which focus on a particular discipline or organ system, for example endocrinology or vascular surgery, see Figure 39. This means the care people with multiple health problems or ‘co-morbidities’ receive can be fragmented, with each problem being treated in isolation, and cumulative or overlapping issues not being addressed. At worst, a lack of coordination can lead to the treatment for one disorder exacerbating other disorders.
Figure 39: Silo curative care models
“The focus on hospital-based, disease-based and self-contained ‘silo’ curative care models undermines the ability of health systems to provide universal, equitable, high-quality and financially sustainable care. [Health systems] are often unaccountable to the populations they serve and therefore have limited incentive to provide the responsive care that matches the needs of their users. People are often unable to make appropriate decisions about their own health and health care, or exercise control over decisions about their health and that of their communities.” Framework on integrated, people-centred health services, World Health Organisation, 201681
5.142 People with a number of co-existing conditions can experience disconnected care because clinicians from different specialties do not always have access to the full patient record. There is sometimes limited specialist overview of the combined medication given to the patient, and clinicians are at risk of making incorrect assumptions about what other specialties are doing for a person.
5.143 People with complex care needs suffer the greatest treatment burden and have a large amount of their time taken up in health and care-related activities. A 2018 study found that in order to comply with all disease-specific guidelines patients with three chronic conditions82 take between 6 - 13 different drugs a day, visit a health professional between c.2 - 6 times a month, and spend around 50 - 71 hours a month
79 https://www.england.nhs.uk/wp-content/uploads/2019/01/universal-personalised-care.pdf 80 http://www.somersetintelligence.org.uk/files/JSNA%202017%20Ageing%20Well%20Summary.pdf 81 https://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_39-en.pdf?ua=1 82 Any combination of chronic obstructive pulmonary disease, coronary heart disease, diabetes, osteoarthritis, hypertension, and depression.
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in health-related activities83. To better value patients’ time, we need to improve the coordination of healthcare interventions and reduce the treatment burden as much as possible.
Aim 5: What will change and how will merger help?
5.144 Personalised care means people have more choice and control about how their health and care needs are met. They are more involved in decisions that affect them and supported to talk about the things or outcomes that matter most to them and the best course of action to achieve those outcomes. Evidence shows that people who are confident in their ability to manage their health conditions have fewer GP contacts and fewer emergency admissions. The NHSEI comprehensive model for personalised care is set out at Figure 40.
Figure 40: NHSEI Comprehensive model for personalised care
5.145 There are six standard components to personalised care:
Shared decision making Personalised care and support planning Enabling choice, including legal rights to choice Social prescribing and community-based support Supported self-management Personal health budgets and integrated personal budgets
83 Claudia C Dobler, Nathan Harb, Catherine A Maguire, Carol L Armour, Courtney Coleman, M Hassan Murad, Treatment burden should be included in clinical practice guidelines BMJ 2018;363:k406
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5.146 The introduction of personalised care has been found to have a positive impact on health inequalities, and people from lower socioeconomic groups are able to benefit the most from personalised care,84 so this work also supports Aim 4. Personalised care can also encompass understanding cultural and other impacts of the way care is delivered and received.
5.147 In the coming years we will fully implement personalised care for people in Somerset in line with the commitment set out in the NHS Long Term Plan85. Working with our partners we will support people to build their knowledge, skills and confidence in managing their health condition and help them to live as independently as they wish.
5.148 It will be easier to implement personalised care across the county when we are one fully integrated Trust because it will be far easier to link up clinicians from different specialisms to support people with multiple needs.
5.149 We will develop our colleagues’ skills in using personalised care approaches in their day-to-day practice, and support the implementation of personal health budgets and integrated personal budgets to give those with complex needs greater control over the care they receive. Evaluation of personal health budgets shows they improve quality of life, reduce reliance on unplanned care eg A&E admissions, and can generate overall savings of £3,100 per person per year.86
5.150 We will roll out patient-centred training to colleagues, to help clinicians have conversations with patients and their families to understand ‘what matters to someone’ – not just what is the matter. In due course we plan to implement a multi- disciplinary case management approach including a single, comprehensive care plan for people with complex needs, although further development of our IT systems will be needed to support this approach.
5.151 To fully implement personalised care in Somerset we need to work closely with our partners in primary and social care and the voluntary sector to bring together the multidisciplinary teams that are needed to care for people with complex needs. These patients sometime require intense focus from a wide range of specialists.
5.152 The creation in south Somerset of Complex Care Teams shows the value that an intense focus by multidisciplinary teams can offer patients with complex needs, see Figure 41.
5.153 South Somerset has three Complex Care Teams each consisting of a GP, nurse and keyworker, supporting 5-6 GP surgeries. The teams are linked into a wide range of health and care professionals in both the public and voluntary sector and can access support from colleagues without referrals. Their work helps to streamline the provision of care for people identified as having complex needs or at risk of crisis. The teams’ interventions enable people to get the right care more quickly by streamlining processes and reducing potential duplication. The teams’ work helps
84 https://www.england.nhs.uk/wp-content/uploads/2019/01/universal-personalised-care.pdf 85 https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf page 25 86 https://www.england.nhs.uk/personalisedcare/evidence-and-case-studies/
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people stay in their own home, lessens the pressure on GPs, and prevents avoidable emergency admissions. Merger offers us the opportunity to extend this model across the county and ensure people with complex needs get prompt care, tailored to their needs.
Figure 41: the value of coordinated care
Case study – South Somerset Complex Care teams
Mary is in her 70s and has Alzheimer’s disease and other complex medical and social concerns. In late 2020, Mary had multiple contacts with her GP surgery, followed by an emergency attendance at YDH A&E and then an acute hospital admission. After her discharge from hospital, Mary’s GP referred her to one of South Somerset’s Complex Care Teams.
The Complex Care Team assessed Mary the next day and were able to engage the right services for her needs. The Team drew in specialists from a range of services to contribute to Mary’s care including the older people’s mental health team, adult social care, the Alzheimer’s Society and relevant input from the team themselves. Six weeks later, once Mary’s health and care needs had stabilised and she required minimal ongoing help, the team set up routine follow-ups to monitor Mary’s ongoing health needs.
5.154 Also under this aim are two county-wide projects. The first, for adults with complex needs, is called ‘Connecting Us’ and aims to better coordinate care and free up people’s time to do what matters to them most. The second project is called ‘Function First’ and aims to improve the life chances of children with complex needs by increasing the time they spend in school. The roll-out of both these projects has been impacted by Covid-19 and progress has been slower than planned.
Aim 5: Benefits
5.155 The anticipated benefits from this aim include:
improved health outcomes and sense of wellbeing for patients and their families from personalised, targeted health interventions greater patient control and involvement in decisions about their care improved patient and carer experience from tailored care and greater knowledge, skills and confidence to self-manage less anxiety and more convenience from care provided closer to home and lower treatment burden more effective and joined up services reduced outpatient appointments, plus fewer emergency attendances and admissions (and an associated reduction in costs) than would otherwise be the case.
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Next steps
5.156 Assuming we get approval to move to Business Case stage, our next steps to work up the detailed clinical strategy will be as follows.
Clinical transformation programme 5.157 We have started to identify the projects and programmes that will deliver our clinical strategy. Appendix 5 presents early ‘Driver Diagrams’ showing our emerging thinking about some of the projects and programme under each clinical aim. At Business Case stage we will further develop the project and programmes that will deliver our clinical vision.
Service integration 5.158 We will bring together all the services in the two Trusts into single county-wide services which will each have a single set of pathways and work to a single waiting list. This is a major programme of work which has already begun in Urology and Oncology, and palliative care. We intend all services to be county-wide within three years of merger.
5.159 This work will be driven by the services themselves and, as services integrate, we will support teams to consider how their service will focus on population health, tackle health inequalities, move more care into neighbourhoods, and adopt a personalised care approach. Services will be asked to focus on getting things right for the person who is receiving the healthcare and their carer(s) and ensure the time of all those who work in and receive our care is valued.
5.160 Each clinical service will set its own priorities and timeline based on what they believe is best for the people they serve. This process will be overseen by the relevant Service Directors.
Clinical and stakeholder engagement 5.161 Our clinical strategy is being developed and led by clinicians from both Trusts, with the involvement of senior representatives from local primary care and social care. We have had to use online engagement tools (because of Covid restrictions) but have nonetheless had good engagement: to date we have received input from over 120 senior leaders from Somerset health and care organisations on our developing strategy.
5.162 We have also engaged with public and patient representatives through our weekly Patient Voice Group which includes people with personal, carer and volunteer experience of our acute, community and mental health services and children’s and adult services. This group is helping to shape our developing clinical strategy and inform our thinking around healthcare buildings and technology.
5.163 Our clinical strategy notes our intention to co-produce our transformation plans with the input of people with experience of our services as well as wider system colleagues. We want to make this easy to do and normal practice. This approach is already well-embedded in some areas such as mental health, but there is more to do in other areas.
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5.164 At Business Case stage we will undertake a wider engagement exercise across both Trusts and the wider Somerset health and care system, to share the key messages of the clinical strategy and help our colleagues identify the key clinical and non- clinical priorities in their areas. We will engage all our colleagues – not just clinical colleagues - as we need everyone to be motivated to drive innovation in the merged Trust. We will continue to work closely with People, Digital and Estates colleagues to ensure their developing strategies fully support the clinical strategy.
5.165 We know from the previous merger of SPFT and TSFT that a positive inclusive approach, good relationships (both within the county and beyond), and ongoing communication are key to the development of a robust and embedded clinical strategy. We have invited colleagues from Dorset HealthCare to attend our strategy groups and will continue to build links with neighbouring trusts.
5.166 We will use a variety of approaches, including group engagement sessions, written information, one-to-one meetings, and focussed work with individual teams to share our plans. We will also develop a short video to tell the story of why we need to transform and how we intend to do it.
Timeline for implementation of clinical strategy 5.167 Our proposed programme of work is significant, and experience from other healthcare systems around the world shows that transforming services is a long-term project requiring 20 or more years to fully implement and embed. We will use a prioritisation tool (based on the aims of our clinical strategy) to help us identify the order in which we take forward our proposed programmes of work.
5.168 If we receive approval to proceed we will set out the detail of our approach to implementing the clinical strategy in our Post Transaction Integration Plan (PTIP).
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6. Supporting strategies
Summary of key messages This chapter sets out the operating model and supporting strategies which will help us implement our clinical strategy. Key messages include: The clinical strategy will be key to our decisions about how we use our resources, and ensure they are targeted at areas of greatest need, in the most effective way. The merged Trust will offer a very wide range of services, from a large number of sites across the county, including peoples’ homes. We have agreed the high-level principles which will ensure the operating model and associated structures are appropriate for the merged Trust. Our clinical strategy is ambitious and wide-ranging, and will require highly engaged clinical and corporate teams to drive through the level of change needed. The merger will boost our ability to attract and retain the right mix of highly motivated, skilled, diverse and compassionate colleagues to deliver our clinical strategy. Digital integration and transformation are fundamental to the delivery of our clinical strategy. Merger will support population health analytics, the roll out of a system- wide electronic patient record and give patients more control over their own healthcare. The combined estates of the merged Trust will aid the delivery of safe, effective, high quality clinical care, support wider work to prevent ill health, and enable care closer to people’s homes. Merger will also enable us to develop a county-wide ICS capital strategy and strategic portfolio of works. Merger would help us tackle the governance issues which arise from variation in pathways across different providers and ways of working across the system. A single governance function would enable us to support teams to develop better and more joined up systems of governance right along patient pathways, and ensure investment decisions are informed by knowledge of where risk lies across the whole county. Merger will enable us to pool our improvement and transformation resource and use it flexibly to provide the whole Somerset system with a single source of data to drive population health management and support improvement activities As a single organisation providing care to more than half a million patients across acute, community, mental health and primary care services, the merged Trust would be a very attractive prospect for clinical research. Merger would give us increased influence in the clinical research network and attract more research funding into the region. Combining our Medical Education teams would enable us to remove duplication, enhance our educational offer through greater breadth of rotation opportunities, and make better use of our combined educational estate. At Business Case stage we will agree our approach to existing joint ventures and YDH’s wholly owned subsidiaries.
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Operating model
6.1 We are at the early stages of considering the merged Trust’s operating model and associated management arrangements, which will support the clinical strategy set out in Chapter 5. The operating environment and context are important considerations when thinking about the operating model for the merged Trust. We recognise that there is no ideal solution and we need to establish structures and ways of working that best support the delivery of our strategic objectives and the clinical strategy. In particularly, the following issues will need to be considered:
The merged Trust will offer a wide scope of service provision, operating from multiple sites and in peoples’ homes. These services and sites will vary significantly in scale and size, including two acute hospitals, 13 community hospital sites, 4 mental health inpatient facilities and a significant number of other community sites. Geographically, the Trust will cover the county of Somerset, with a wider reach into neighbouring counties for a range of services. This means covering a population of more than 600,000 spread over an area in excess of 1,600 square miles, which is predominantly rural with a number of small to medium-sized towns.
6.2 We have agreed the following high-level principles which will be used to inform the operating model and associated structures for the merged Trust. The operating model will:
enable the realisation of the ambition set out in the Trust vision, strategic objectives and the clinical strategy. This includes a population-centric approach, supporting physical and mental health care needs. support the development of an environment that enables colleagues to thrive in their roles and that is open and inclusive, whilst embracing and celebrating the individual identities of different services and teams. recognise the importance of neighbourhoods and localities to the delivery of health and care to the population and that more specialist services will be managed at a level that makes most sense in terms of scale, efficiency and sustainability. incorporate clear ways of working with other local partners, including primary care, social care and the voluntary sector in a way that supports population health management and the integration of care. seek to support the integration of services in a way that makes most sense to the people we serve, and do so in a way that is streamlined, consistent and efficient without unnecessary duplication. allow for flexibility to recognise the breadth and scope of the service portfolio and the range of care settings, whilst ensuring equity of access for patients, carers and families. support a data and analytics driven approach to service planning and population health management.
6.3 In the coming months, we will develop these principles further and consider options for the operating model with input from colleagues and learning from other models, both in the UK and internationally.
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People
6.4 Our approach to our People determines our ability to attract, retain and deploy colleagues effectively and ensure they have a positive experience at work. This makes it key to the success of our proposed merger, and the successful implementation of our clinical strategy.
6.5 There are many cultures within SFT and YDH largely because of the breadth of services and sites that the two Trusts operate. We want to retain cherished local identities while harmonising cultures and taking the best from both organisations. We are committed to creating an environment where all our colleagues feel they belong, have autonomy and are able to innovate and flourish.
People: current challenges
6.6 Owing to their size, the Trusts currently have difficulty recruiting to some posts, such as mental health and community nurses, radiographers, physiotherapists, occupational therapists, dieticians and pharmacists (see paragraph 2.38). The relatively small size of some of the Trusts’ services means they are less resilient, and our career pathways and learning opportunities can be more limited than those offered by larger trusts. In addition, the current differences between the recruitment processes of the two Trusts means potential duplication for colleagues as they move between health posts within the county.
6.7 20 per cent of the nursing workforce in Somerset could potentially retire within 5 years and both Trusts currently rely heavily on international recruitment to fill vacancies. Somerset lacks a university based in the county, and more young people leave Somerset compared to other counties, due to a lack of career and learning opportunities. These facts impact on our ability to recruit to clinical roles.
People: benefits of merger
6.8 The proposed merger will enable us to develop and implement an integrated People strategy which helps attract high calibre, diverse applicants, improves our resilience and makes the merged organisation a great place to work. This, in turn, will support the delivery of the clinical strategy.
6.9 The proposed merger will also benefit our Equality, Diversity and Inclusion agenda by enabling us to bring together initiatives of good practice in each Trust. This will help our work to ensure all colleagues are free from discrimination, feel equally supported in achieving their career aspirations and have a high level of job satisfaction. It will also help us progress our objectives for attracting, developing and retaining a diverse workforce by offering new and more flexible career opportunities. Merger provides the
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opportunity to focus on nurturing a positive change culture, whether it relates to recruitment and workforce planning, performance and progression or bullying, harassment and victimisation. As a larger and more diverse merged organisation we will be able to offer:
A more attractive and rewarding offer to existing and potential colleagues due to greater career and training opportunities across our county-wide acute, community, mental health, learning disabilities and primary care services. This will be supported by the use of flexible/rotational roles and portfolio contracts, and support to colleagues to work at the top of their licence. We will be able to offer innovative new roles in support of our clinical strategy such as Advance Care Practitioners and other multi-disciplinary roles that support primary and secondary care, and more system-wide roles (see Figure 5). It offers the opportunity to expand YDH’s innovative overseas recruitment programme across the county (see Figure 42). The new YDH residence development will also enhance our colleague offer through the provision of high quality, modern accommodation in Yeovil. A single recruitment process for colleagues who join the merged Trust with greater freedom to switch base location across our wide range of sites in Somerset. Enhanced colleague training and opportunities to share skills. Broader and more vibrant colleague networks. Wider research opportunities resulting from the focus on population health, broader range of services and the higher volume of patients served by the enlarged Trust. Greater colleague resilience as a result of larger services, a single county-wide staff bank and more influence with (and hence better rates from) staffing agencies from which we draw temporary colleagues.
Figure 42: YDH overseas recruitment programme
YDH has developed an innovative overseas recruitment programme which has enabled it to support 18 other trusts across England and place over 1,300 nurses and 32 radiographers in the last two years. YDH is a centre for recruitment in the south of England and has pledged to deliver a proportion of the 50,000 additional nurses required by the NHS.
The impact of the overseas recruitment programme means that YDH generally has no or very few ward-based nursing vacancies. The programme has also helped fill 105 nurse and 1 radiographer vacancies at SFT.
Merger would support the spread of this innovative approach across the county and would give us a larger pool of clinical staff to take overseas to undertake interviews. It would also add credibility to our Mental Health recruitment programme.
6.10 YDH and SFT are currently developing plans to align their Inclusion strategies. Alongside this, Somerset’s health and social care organisations have agreed a set of equality objectives for 2019-2024, (see Figure 43). The bringing together of acute, mental health, community services and primary care in the proposed merger will put us in a better place to provide holistic care to marginalised groups and to implement the
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Accessibility Information Standard87. Supporting communities to stay safe and well requires close working with other health and care providers, public services and the voluntary sector, and merger will also aid this because partners will have only one NHS Trust to engage with rather than two.
Figure 43: Somerset equality objectives
1. We will work with communities to improve the opportunities for integration and cohesion. 2. We will improve public understanding of mental health. 3. We will work with the Gypsy and Traveller community to improve relationships. 4. We will create an equality working group for colleagues in the public sector in Somerset. 5. We will implement and review the Accessibility Information Standard to create consistency around its implementation.
People: enabling the clinical strategy
6.11 Our clinical strategy is ambitious and wide-ranging, and we need highly engaged clinical teams to drive through the level of change needed. We will need the appropriate mix of highly motivated, skilled, diverse and compassionate colleagues. They will also need a clear understanding of our clinical strategy, and the autonomy to work creatively and innovatively in support of that strategy. Our People strategy will set out our plans to ensure the climate our colleagues are working in promotes this way of working.
6.12 We have already started linking up clinical colleagues with similar portfolios and objectives to share ideas and build trust, as well as colleagues from a range of corporate services across training & education, learning & development and transactional HR.
6.13 From 2021, University Centre Somerset (part of Bridgwater and Taunton Further Education college) will offer degree-level nursing programmes accredited by UWE (Bristol). In the first year, our two Trusts expect to support around 60 Nursing Associate Apprentices and 60 Registered Nursing Degree Apprentices who will study at the Centre. Although both Trusts already invest in nursing apprenticeships, the sustainability of our investment will be more assured when we are an enlarged Trust. This in turn supports the sustainability of the University Centre programme, and helps provide a strong pipeline of nurse associates, registered nurses and registered mental health nurses to work in the merged Trust.
6.14 The merged Trust will also be able to offer a greater number of undergraduate placements across a range of other clinical professions and provide those students with a broader learning experience than we could as separate Trusts, as a result of a greater breadth of services, as well as larger services caring for a higher number of patients.
87 The standard sets out a specific consistent approach to identifying, recording, sharing and meeting the information and communication support needs of patients, service users, carers and parents with a disability, impairment or sensory loss. https://www.england.nhs.uk/ourwork/accessibleinfo/
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6.15 Through our role as a significant employer in Somerset, providing training and career development, and supporting a significant amount of volunteering we will play a strong role in the social and economic development of the county.
People: next steps
6.16 We have already begun to take steps to integrate our HR functions (see paragraph 3.41). This work will continue up to and beyond merger date to ensure a smooth transition to an integrated team and will involve close working with our union colleagues on policy and process changes.
6.17 If we secure approval to move to Business Case we will develop a joint People strategy which supports integration across the merged Trust. We will develop our joint strategy by drawing on data about our strengths and areas for development from sources such as the latest staff survey results and our People Key Performance Indicators (KPIs). We will also bring together our senior People teams so they can talk about the work they are proud of, discuss the risks and challenges, and share what excites them about our proposed merger. We will exchange detail about our ways of working and HR systems. This work will help us shape our strategy and identify our priorities.
6.18 Our focus will be on learning from each other and spreading good practice from each organisation. We will engage with our colleagues across both Trusts to understand their perspective and also link with the LWAB (System workforce group) to develop our strategy. We will ensure the objectives of the national and regional People Plans are woven through our strategy. We will adopt a phased approach to ensure good engagement and regard for colleagues as we go through this change and start to shape our future.
6.19 Our joint People strategy will set out how we will deliver HR, recruitment, education and training services as an integrated HR service. It will also set out the new and innovative roles we will offer and how we will support agile and flexible ways of working.
6.20 Each Trust has positive individual cultures as demonstrated by the staff survey results and other engagement tools. This will be celebrated and built upon at a pace that is respectful of individual starting places and supports the vision of the clinical strategy.
6.21 Our joint People Strategy will set out our approach to Organisational Development (OD) and our work to engender the decentralised operating model that will be required if our clinical strategy is to take root. We will engage with colleagues and consider the following OD work over the life of the People strategy:
Interventions which define the future, including framing our values, behaviours, ways of working, principles and expectations. Interventions which communicate, excite, engage and involve colleagues in the vision of the future and their role in delivering it. Interventions which equip colleagues with the skills, capabilities and tools that are needed to bring the values of the merged organisation to life.
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Interventions which embed and reinforce the desired future state of the organisation through policy, practice, structures, forums and the way in which individuals and teams are held to account.
Digital
6.22 The success of the proposed merger and delivery of the expected benefits depends on us getting digital integration right. The Covid-19 pandemic has increased people’s willingness and ability to engage digitally with healthcare.
6.23 SFT is a Global Digital Exemplar (GDE) and the foundations of the GDE approach have aided SFT’s digital transformation and supported its pandemic response. SFT is one of the first trusts to conclude the 4-year GDE programme and it is seeking accreditation and assessment of its digital maturity in autumn 2021, with an updated HIMMS (Healthcare Information and Management Systems Society) assessment - aiming to achieve level 6 (out of 7).
6.24 YDH has expertise in app development and has developed a web app which enables Trust teams and patients to communicate and share information. This work demonstrates the opportunities that exist to redesign how we support people with long- term conditions, or those who are waiting for treatment. YDH has also developed expertise in population health management through the Symphony Programme, by using patient-level linked data to highlight at-risk groups of patients and develop new care models.
6.25 SFT’s learning from its GDE status will support the creation of an integrated clinical and digital leadership team for the merged Trust, alongside learning from both Trusts and best practice models for delivering digital transformation. The open standards used by both Trusts and the inclusive development model used for system and data integration will be adapted and adopted for the merger. Bringing together the two Trusts’ Digital teams will enable us to improve the use of digital technology and data across the merged Trust and the wider system. It will also help us connect health and care providers, improve outcomes and put the people of Somerset at the heart of their own care.
6.26 Digital development and integration are fundamental to the delivery of our clinical strategy and operating model. Our ‘digital first’ approach will enable us to drive improved quality of care, safety, and financial efficiency across clinical and corporate services. Each of our clinical aims will be supported by digital processes and technology, including patient support and information, appointment bookings, remote monitoring of long-term conditions, virtual outpatient appointments and the operation of virtual wards. Implementation of our digital strategy will support the transformation of our services and the way we deliver care in our estate.
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Digital: current challenges
6.27 A mix of modern and legacy digital systems are currently in operation at the two Trusts. We do not have a single care record, although the SIDeR programme which is currently in early implementation across the county offers some shared access to patient data.
6.28 There are historic information governance challenges in sharing information between the two Trusts, driven by the need to have a data sharing agreement in place for each data item that is shared between the Trusts and also concerns historically, about sharing potentially commercially sensitive information.
6.29 Although there is a great deal of digitisation, both Trusts have some historic paper- based medical records and use telephone or letter-based booking systems which are inefficient and carry inherent information governance and patient safety risks. This means that in many cases we lack a full patient history in our electronic records. Our systems are also currently unable to link easily with medical devices such as fitness monitors worn by patients.
6.30 Our clinical strategy focuses on population health management, but our current capability to generate actionable population health data, both within the Trusts and across the Somerset system is low. Our digital teams are stretched due to ever increasing legal requirements, the drive to modernise, and central requirements for information e.g. relating to the pandemic response. In addition, the digital capability and readiness for digitally-driven change of our front line colleagues is mixed, and is low in some cases.
Digital: benefits of merger
6.31 Combining our two digital teams means we would be able to draw on the strengths of each Trust and create a larger pool of IT resource to be deployed flexibly across the county. YDH’s digital team has a track record in app development and process automation. SFT is a Global Digital Exemplar (GDE) and has blueprinted an integrated approach to digital procurement, development and implementation; the success of its combined clinical and technical digital leadership team has been nationally recognised.
6.32 Merger would enable us to strip out duplication in reporting and system maintenance and redirect the freed-up resource elsewhere. Merger would also facilitate more cost- effective procurement due to the greater purchasing power of the combined Trust.
6.33 As a single legal entity, information sharing issues would fall away making it easier to share data which supports patient safety and promotes efficient operation.
6.34 The core patient administration and patient record systems across both Trusts are due for contract renewal in 2025. This gives us a chance to review the provision of the
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main clinical systems, and merger means we may be able to invest in systems which would not have been viable or affordable as individual Trusts. A single procurement exercise for a single system will reduce costs, and we will be able to use our combined team resource to accelerate implementation and delivery of benefits.
6.35 Delivering a ‘digital first’ agenda across our service provision provides opportunities to manage the way we work across the county, building on the opportunities for remote working and new ways of working from Covid-19.
Digital: enabling the clinical strategy
6.36 There are a number of ways in which the digital agenda will support the implementation of our clinical strategy. These include:
Population health: The ability to gather, store and share clinically valid population health management data, supported by data analytics, to support the targeting of resources to reduce health inequalities and enable people to stay healthier. Integrated, personalised care: A shared health and care record to support integrated care (this is being pursued in the OpenEHR platform, the clinical data repository and under the SIDeR programme). Optimising the patient pathway and putting individuals in control of their healthcare is key to delivery and patient access to records. The provision of options for accessing healthcare including remote consultations, remote assessment, provision of information to support individuals in their care. Valuing people’s time: Using artificial intelligence will enable quicker and more reliable diagnosis to improve patient safety and reduce waits. Single sign-on for colleagues to access electronic records. Supporting self-management: Enabling patients to have easy access to their health and care information and input their own data to their health records or link to their own devices. This would give greater depth of information, enable new ways to support patients alongside face-to-face consultations, and improve patient experience. Efficiency: Deploying paperless solutions including a self-serve booking system to increase responsiveness and control for patients in booking their appointments and reduce administration costs and errors. An enhanced integrated digital record will significantly improve the efficiency of our operations and use of clinical capacity, providing opportunities for reduction in length of stay in bedded facilities, reduction in admissions, contacts and appointments through remote monitoring. Continuous improvement: Using business analytics and intelligence to support the continuous improvement of our services, via clear and consistent measurement in line with national best practice, led by the GIRFT and Model Hospital approaches.
6.37 Our Digital teams will work together with the YDH2030 and Musgrove2030 teams to ensure our digital transformation aligns with our capital Estates programmes.
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Digital: next steps
6.38 The two Trusts’ Digital teams have been working together for some time on the SIDeR programme, and more recently on the Covid-19 vaccination programme. The Trusts also have some shared digital infrastructure posts.
6.39 If we get approval to proceed to Business Case we will develop a joint digital strategy. This will be informed by national and international best practice, benchmarking, SWOT analysis88 of our teams and services, estimated costs and benefits, and options for service models and staffing models. As the digital strategy progresses there will be continued focus on co-production and patient engagement regarding digital solutions and the use of patient data. This will be allied to an ongoing programme of colleague engagement and training. We will create a joint team to market test the provision of a new joint electronic patient record system.
6.40 We will also conduct a detailed audit of our combined digital workforce by band and function and catalogue all our digital systems and relevant budgets. We will assess the digital maturity of each Trust and agree the standard practices to be adopted across the new merged team.
6.41 The key patient record systems currently in operation at the Trusts are due for re- procurement in the next 2-3 years. If we get approval to move to Business Case stage we will undertake detailed work to consider whether a single EPR or an open system alternative would best support the provision of integrated care across the merged Trust’s wide range of care settings.
6.42 Development of our joint Digital strategy will be clinically-led and support the connected healthcare model, which uses digital technology to help patients play an active role in supporting their own health. Our joint Digital strategy is likely to include the following:
Increasing our capacity to generate population health management data to support informed decision-making across the Somerset system. Developing our automation capability to support operational and clinical processes. Investing in the development of digital skills across the merged Trust, including the training and up-skilling of staff in using digital tools, and raising colleagues’ digital confidence in day-to-day work activities Ensuring the inter-operability of our systems using national open standards to enable a single view of the patient Investing in artificial intelligence to support quicker, more reliable clinical diagnosis Continuing the drive to paperless solutions to realise efficiencies, including automated self-service processes Rolling out processes which enable patients to share personally collected health data Joint procurement of digital system replacements which support the creation of a single electronic patient record and common use of SIDeR.
88 Analysis of Strengths, Weaknesses, Opportunities and Threats.
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Closer working with transformation and clinical teams to understand their services’ data and improve the merged Trust’s performance on Model Hospital benchmarking.
Estates and facilities
6.43 We will use the combined estates of the merged Trust to aid the delivery of our clinical strategy by facilitating the provision of safe, effective, high quality clinical care, support wider work to prevent ill health, and enable care closer to the patient or service user’s home. We are developing our estates and digital strategies in close conjunction, because the way we use digital to deliver care now and in the future has a strong influence on our estates requirements. The estate and environment in which we provide our services are much more than a place to house our services. The provision of therapeutic environments which are easily accessible and have access to outdoor space, is core to our clinical strategy and there is good evidence of their role in accelerating and supporting recovery.
Estates challenges
6.44 Both Trusts face issues around constrained and outdated estates, and both acute hospital sites have a high level of backlog maintenance. It is estimated that SFT’s total investment need is c.£44.2 million89. The estimated value of backlog maintenance at YDH is c.£11.2 million.90 The key estates challenges at Yeovil District Hospital include ageing infrastructure, an old ward model (large wards with 6-bedded bays, no co- located toilets and non-clinical office space on the wards), an under-sized emergency department, and insufficient theatre and diagnostic space to cope with Somerset’s growing elective care demand. YDH has had no national capital investment in recent years and as a result has only a small capital team. This in turn has created difficulties for YDH in progressing large-scale capital plans.
6.45 SFT’s main estates risk is the ageing infrastructure at Musgrove Park Hospital (MPH). Although investment has been secured to replace the old theatre and critical care facilities, there remains a considerable proportion of the estate which dates back to the 1940s. For example, the maternity, neonatal unit and Children’s department are in aged estate which is not fit for purpose, undersized for the current capacity and modern clinical standards. There are a number of other facilities including ward areas, treatment facilities and screening areas which are also delivered in buildings from c.1945 and which require replacement. Although the Musgrove2030 programme will significantly reduce the level of backlog maintenance on the site and address the historic capacity issues and resultant challenges around waiting times, the need for ongoing investment will remain.
89 2021-2026, excluding on costs 90 2021-2026 excluding on costs; figure as at October 2020.
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6.46 There has been significant investment in SFT’s community and mental health estate in the past 10-15 years, although some issues exist which require financial investment.
6.47 In addition, both Trusts are at risk of losing critical technical estates skills and corporate knowledge from a combination of local competition for skills from large infrastructure projects (notably Hinkley Point C), and the fact that our estates teams are comprised largely of an older demographic. This contributes to the challenges in maintaining a safe environment for colleagues and patients alike.
Current capital programmes
6.48 YDH and SFT each has a capital programme underway which, in addition to our existing capital plans, are intended to ensure our estates meet modern standards for clinical safety and quality and enable us to meet environmental targets. The programmes are known as YDH2030 and Musgrove2030 respectively and both are currently at Strategic Outline Case stage. These programmes, are based on a single, shared vision and will help provide the physical infrastructure to realise our clinical strategy.
6.49 YDH2030 (value c.£100 million) includes a new surgical centre which will help us implement our model for managing elective capacity in Somerset, expand YDH’s emergency department to meet future demand, and upgrade YDH’s wards. Musgrove2030 (value c.£450million, funded by the New Hospital Programme) will replace some of the oldest healthcare buildings in operation in England with modern facilities at the Musgrove Park site specifically the Maternity, Neonatal and Children’s facilities.
6.50 SFT’s existing capital plans include the provision of an additional inpatient Mental Health Ward in Yeovil (c.£8.5m) the re-provision of Theatre, Critical Care and endoscopy facilities (£87m) and the development of an Acute Assessment Unit (£11.4m), in addition to the ongoing maintenance and delivery of digital capability.
Estates: benefits of merger
6.51 Merger offers the opportunity to manage a significant proportion of the healthcare estate in Somerset to drive our aim of providing services within neighbourhood areas and ensure our estate supports the effective and efficient delivery of high-quality healthcare.
6.52 Coming together would mean we can make the most of each other’s expertise, capacity and resources. We would be able to develop a county-wide ICS capital strategy and strategic portfolio of works which would strengthen Somerset’s chances of winning future capital allocations, as well as enable each hospital to support the other in ways not done previously. For example, we could increase ophthalmology
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capacity on the Yeovil site to support county-wide recovery, where previously this would not have been justified by the local position in south Somerset.
6.53 We will be able to standardise major capital equipment and run single procurements which will yield savings. Likewise, a combined facilities management team would also benefit from greater buying power.
6.54 Combining our two capital development teams and our two facilities management teams would create a bigger critical mass of estates and facilities expertise, support the sharing of best practice, and bring greater capacity and resilience to work flexibly across the county. For example, SFT’s estates and facilities staff currently maintain Burnham-in-Sea community hospital, while their YDH counterparts91 maintain the Burnham GP practice. Merger offers the opportunity to rationalise and align teams to reduce travel time across the county and ensure efficient use of resources.
6.55 Merger would also mean we could appoint to single county-wide Authorised/Competent person roles to ensure service resilience and reduce reliance on contracted out services. Bringing the two Estates teams together would also support the delivery of our capital build programmes through the aggregation of the teams’ capacity, skills and expertise.
6.56 Combined teams would also offer improved career and development opportunities for individuals, thereby improving recruitment and retention, and strengthen team succession planning. A combined facilities management would also have greater capacity to respond in the event of a major incident or site issue.
6.57 YDH currently provides maintenance of community and mental health estate and medical electronics services to SFT under a service level agreement (SLA). Merger would enable us to eliminate the significant work involved in managing and reporting under this agreement.
6.58 With a joint estates team, working to a county-wide strategy, we will be able to build on our role as an anchor institution in Somerset, and maximise our economic input though the investment and redevelopment of our estates.
6.59 Having a county-wide investment strategy for the acute sites will strengthen our ability to recruit and retain colleagues by providing modern and engaging spaces in which to work. For example, works completed on YDH’s ambulatory emergency care unit have shown how good design underpins clinical pathway improvements and colleague engagement.
Estates: enabling the clinical strategy
6.60 Our estates are a key enabler to the delivery of our clinical strategy. For example, on elective care, working county-wide will enable us to develop a comprehensive and longer-term plan to respond to rising demand in Somerset, rather than viewing things
91 Staff employed by Simply Serve Limited.
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through the lens of each individual Trust. Merger also offers the opportunity to broaden our use of the existing properties and access to over 150 locations across the county within the two Trusts’ combined portfolio and direct them in the service of the clinical strategy, alongside the wider healthcare assets in primary care.
6.61 We are committed to ensuring our estates work for the people that use them and help deliver our clinical strategy. Our estates will be safe, well-maintained, effective and welcoming, and support our aim to value all people alike. They will also reflect our design aspirations. We have already agreed some principles which will underpin our joint Estates Strategy, see Figure 44. We are using these principles to inform our planned capital works. More detail on these principles is set out in Appendix 9.
Figure 44: Principles of our joint Estates Strategy
Our estates will:
Work for the people that use them Help to deliver our clinical strategy Be safe, well maintained, effective and welcoming Support our aim to value all people alike Reflect our design aspirations
We will do this by following 5 principles:
1. Ensuring that the health estate meets the objectives of the clinical strategy through promoting safe, effective, high quality care delivered in the most appropriate setting and through enhancing health and wellbeing. 2. Ensuring that the health estate promotes colleague wellbeing and productivity. 3. Ensuring the current health estate is fully and effectively utilised and reducing estate where it is not required or not cost effective to maintain. 4. Ensuring that current health estate is fit for purpose. 5. Reducing the running costs of the health estate to enable better use of resources.
6.62 It is essential that our services are environmentally sustainable, and we aim to be a carbon neutral trust by 2040. We will focus on the design and operation of our facilities over the next ten years to meet this target, as well as our interim aim to reduce our carbon footprint by 80 per cent by 2030.
6.63 The role of digital in helping us reduce our carbon footprint and estates requirements will be a core element of the estates and clinical strategies. For example, the impact of remote working on commuting and on-site office space requirements, the potential to coalesce office space into hubs on both sites, and the role of virtual clinics all have the potential to decrease non-clinical space needs and travel associated with healthcare. How an increase in digital models of care delivery and remote working impacts our carbon footprint will need to be closely monitored and accounted for.
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Estates: supporting social and economic development
6.64 Improved estates (and closely associated investment in digitally-enabled care) will help drive improved patient care and experience, less time spent in healthcare and improved quality of life. This in turn frees people to have more productive social and work lives, thereby contributing to the broader social and economic development of the county.
6.65 SFT has struggled in recent years with lack of space at the Musgrove Park hospital site. Meanwhile Somerset County Council has wanted to let or sell part of its estate to help improve its financial position. Central government funding under the One Public Estate initiative has enabled SFT to take on a 10-year agreement to use 150 desk spaces at County Hall in Taunton. This will make a positive contribution to the local government financial position in Somerset, as well as easing accommodation pressures on the Musgrove site.
6.66 The development of a joint sustainability plan will support the delivery of the net zero carbon target by 2040 and ensure we are at the forefront of delivering environment sustainability within the county.
Estates: next steps
6.67 If we get approval to proceed to Business Case we will develop a joint estates strategy that is based on two key foundations: our agreed clinical strategy, and our shared understanding of future demand. We will continue to pursue both capital programmes YDH2030 and Musgrove2030 and will prioritise estates developments on the basis of county-wide need, the reduction of health inequalities, and maximising patient and colleague benefit. Our joint estates strategy will include capital pipeline development which reflects the capital programme over the next 5 years, including the maintenance programme, and will ensure that funding is directed where in the county it is needed most.
6.68 The first step in the joint estates strategy is the development of a joint estates design vision which outlines the approach for the design of healthcare environments for the next ten years. We will ensure the approach to the joint estates strategy is developed in alignment with our other merger workstreams to ensure the combined estate meets the requirements of the clinical strategy and operating model for the merged Trust.
6.69 Once we have approval to move to the next stage, we will also agree the operating model for estates delivery, facilities management and capital development across the merged Trust.
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Integrated governance
Governance: current challenges
6.70 Both Trusts currently have a relatively lean governance team, with limited resilience. Furthermore, the different incident and reporting systems and contractual arrangements in place at each Trust create some limitations in learning and triangulation.
6.71 The two Trusts were both rated ‘requires improvement’ for the Safe domain at their most recent CQC inspections (see Figure 4).
6.72 Both Trusts have a ward accreditation programme to support the sharing of best practice across nursing teams and provide ward to board assurance that high quality care is being delivered. However, the two Trusts are currently using different approaches to ward visits, data collection and the gathering of patient feedback. Merger would make it easier to bring consistency to this programme and thus patient care right across the county.
6.73 The Trusts identify governance issues requiring action from a range of sources including reviews of deaths, incidents, complaints and claims. Regulatory and commissioning requirements mean that each of these areas tends to have separate processes to provide evidence of learning to external stakeholders. Sometimes the changes made in response to issues identified are short-term e.g. reviewing policies, raising awareness and providing training, rather than making changes that fundamentally tackle the issues identified. Some of the issues arise from variation in pathways across different providers and ways of working across the system, and merger would help us tackle these deeper issues. Merger would also help us bring consistency to our processes for learning, along with softer intelligence from colleagues, and focus on making real, sustainable changes which are supported by improvement methodology and shared across the county.
Governance: benefits of merger
6.74 Bringing the two Trusts’ integrated governance functions together will offer greater assurance over the safety and quality of care of patients and colleagues across the county. A single risk register will help us set the goals of the merged Trust and ensure investment decisions are informed by knowledge of where risk lies across all our sites in the county. As a combined governance team we will be able to make better use of intelligence, learning and best practice to drive improvements in care.
6.75 We will be able to provide improved specialist advice, information, education and understanding of governance to our colleagues. We will also be able to support teams and services to develop better and more joined up systems of governance right along
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patient pathways. Merger will also reduce costs (by removing duplicate reporting) and increase the resilience of the combined governance team.
6.76 It will be the ambition of the new Trust to improve its CQC rating for the Safe domain and ultimately its overall rating. The continued integration of mental health services with acute services will support the areas requiring improvement identified at YDH. Consistencies in approach to record keeping – including the development of the digital agenda – will strengthen this area for the merged Trust. Management of waiting times on a county-wide basis will enable a consistency and equity of approach supported by effective monitoring and governance.
Governance: next steps
6.77 Our corporate strategy will set out the shared vision and strategic objectives of the merged Trust (see paragraph 2.30) and we will use this as the framework for the integrated governance of the merged trust. If we receive approval for the proposed transaction, we will merge our Board Assurance Frameworks (BAF) into one document to focus Board and Sub-Committee attention on achievement of our agreed corporate objectives. The BAF will be supported by Key Performance Indicators to assure improvement and/or flag risks to achievement.
6.78 In advance of merger date, we will align our processes used to identify, report and manage clinical and non-clinical risks so that we can ensure a consistency of understanding and reporting of risk across all our clinical services and corporate functions. As is currently the case in the individual Trusts, the corporate risk register for the merged trust will be reviewed on a monthly basis at the key operational committees and quarterly by the Board of the merged Trust, with the overall process for risk management being overseen by the Audit Committee.
6.79 The Trust will develop a single framework of governance assurance reporting, representing the full scope of compliance requirements across all services, including clinical governance, information governance and health and safety, aligned to the delivery of the agreed strategic objectives and legal and regulatory requirements. We will develop a single process for learning from incidents and other events to ensure shared learning across the merged Trust.
6.80 Quality Governance will be a key element of the overall governance arrangements of the merged Trust. The Board will have oversight of quality through an aligned Quality and Performance Report which will be presented to the Board of the merged Trust at each meeting. It will highlight the key issues and trends, in relation to the provision of high quality care, patient safety and patient experience against the national oversight framework and local quality performance targets. The Board will also receive regular assurance reports from its delegated sub-committees.
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Improvement & transformation
Improvement: current challenges
6.81 Historically Somerset has struggled to collaborate effectively on change programmes. Duplication in projects and programmes has meant senior colleagues have been asked to attend multiple meetings on the same topic. For example, there were four separate groups looking at Outpatient Transformation in the county until the Somerset Integrated Project Team (a collaboration between the providers) was established. The benefits of some projects were unclear, and in some cases the objectives of similar projects were at odds. Partly as a result of this, some projects had poor clinical engagement. The use of external management consultants to run the programme management office for Somerset STP meant transformation work was disconnected, and the system missed opportunities to spread emerging benefits.
6.82 There is however a strong track record of the delivery of quality improvement programmes across both providers. At SFT the improvement team, approach to quality improvement and capacity for transformation have been recognised nationally through the Q Community92, the Advisory Board and were noted as good practice by recent CQC inspections.
Improvement: benefits of merger
6.83 Merger will enable us to pool our improvement and transformation resource and use it flexibly to address system priorities. Shared resources will allow us to develop better relationships and awareness by team members working across locations. Crucially, blending the teams will support us to guide teams to seek collaborative solutions that make the best overall use of resources rather than focussing on traditional siloed solutions.
6.84 As part of our work to integrate our two Improvement teams we have already:
created the Somerset Collaboration Hub using resources from YDH, SFT and Somerset County Council. We are one of only a handful of systems in England using this model of integrated Improvement team, which will provide us with a single source of data to drive population health management and support improvement activities begun baselining our system-wide projects to aid evaluation against system priorities and identify areas for further support from the integrated Improvement team updated our system governance to support the formation of the Somerset ICS and the operation of the Collaboration Forum which leads system change
92 Q is an initiative connecting people, who have improvement expertise, across the UK and Ireland. It is delivered by the Health Foundation and supported and co-funded by partners across the UK and Ireland. https://q.health.org.uk/about
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across the Somerset system and includes representation from all Somerset providers taken back operation of the system Programme Management Office (PMO) which was previously led by external management consultants. This ensures change is ‘Somerset-led’ and has reduced the cost to the system of c.£100,000 per annum developed plans to accelerate integration of the Improvement teams following the pandemic.
6.85 Merger will make it easier to combine our two Improvement teams to work across all Somerset health and care organisations and programmes. In turn, this enables us to:
bring together the improvement and transformation strategies and priorities into a single system-wide approach drive cultural change by supporting teams to own and implement change within their teams and services drive collaborative, system-level solutions to problems that make best overall use of resources make more efficient use of the specialist expertise of our Improvement, Transformation, and programme management colleagues, and create a more resilient Improvement team implement a single evidence-based approach to improvement, using a single suite of tools, templates and reports and a single set of project management and Quality Improvement training programmes streamline our governance and reporting processes to enable visibility, coordination and the tracking of benefits against system priorities combine duplicative projects being run separately across YDH and SFT into single system projects which align to the system strategy deliver system-wide change more quickly and at greater scale incorporate the System Analytics team into the single Improvement Team to support the targeting of programmes at the areas of greatest need and enable measurement of progress.
Improvement: next steps
6.86 If we secure approval to proceed with the proposed merger, the next steps in the integration of our Improvement teams are:
Finish baselining all projects across secondary care to assess where projects can be brought together deploy ‘PowerHub’ (our jointly procured PMO tool) across the YDH and SFT improvement teams. This will allow a single view of all programmes and projects, assessment of benefits, timelines and dependencies further refine the role of the Collaboration Forum to help drive change aligned to system priorities deploy Improvement team resources to support restoration and recovery from Covid-19 finish establishing the Somerset Collaboration Hub to include integrated analytics resource, and the adoption of PowerHub by all system partners to give a single view of change and transformation
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complete the integration of the two Improvement teams at YDH and SFT into a single team, working to a single improvement agenda.
Clinical research
6.87 Good clinical research goes hand in hand with high quality clinical care and there is good evidence that patient outcomes are better in organisations which are active in research.
6.88 SFT is a medium-sized player in the regional Clinical Research Network but is one of the biggest recruiters into clinical studies in the region, relative to its size. CQC’s last inspection of Musgrove Park Hospital noted the Trust’s strong culture and ethos around research.
6.89 YDH is the smallest acute trust in the South West clinical research network. The Trust has a good reputation in recruiting to research and consistently appears in the National Institute for Health Research’s top ten small acute trusts league table for recruitment and complexity of studies. In some services eg oncology, the lack of substantive consultants means the Trust has to turn down studies due to a lack of clinicians with the capacity to take on research. This has a knock-on effect on recruitment as research plays a big part in attracting high-calibre staff.
6.90 As a single organisation providing care to more than half a million patients across acute, community mental health and primary care services, the merged Trust would be a very attractive prospect for both formal research as well as improvement and innovation projects. It is complex to run trials along clinical pathways which span multiple organisations and merger would remove these complexities.
6.91 Merger means we will be able to increase the patient cohort for studies whilst reducing administrative overheads, have increased influence in the clinical research network, and attract more research funding into the region. A stronger body of research would help us go further in reducing differences in care, give patients access to novel treatments across all sites, and provide colleagues with training in up-to-date investigations and treatments. Additional business opportunities with commercial partners may also become possible with the larger volume of patients.
6.92 The two Trusts established the Somerset Research Collaborative some years ago and have run several clinical trials under it. However, staff need to have an honorary contract to enable them to access IT systems etc. at the different sites. In a merged Trust these barriers would be removed, making it easier to run research studies across all locations and reducing the associated administration for HR teams and managers.
6.93 Staff at both Trusts have good links with the universities in the region, the South West Academic Health Science Network, National Institute for Health Research, and the Peninsula Collaboration for leadership in applied health research and care (PenCLAHRC), and through these we can attract high-calibre staff seeking career progression. Merger will enable us to better leverage these links and make a more
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attractive offer to potential recruits by offering research time as part of medical job plans and nursing roles.
Medical education
6.94 Both Trusts have existing strengths in medical education. YDH is nationally recognised for its support to doctors achieving their CESR93, and SFT has achieved excellent educational ratings from Health Education England. Merger would enable us to combine our medical education teams and associated facilities and remove duplication. The two Trust teams have already started working together, specifically on a joint procurement exercise for medical workforce software. YDH and SFT now use the same software packages for job planning, appraisal and revalidation and other related functions.
6.95 Merger offers the opportunity to adopt a consistent approach to medical education across Somerset, and remove the doubling up of key medical education roles such as the Guardian of Safe Working, BMA representatives and so on. Merger will enable us to enhance our educational offer through greater breadth of rotation opportunities, and better use of our combined educational estate – the YDH Skills Lab and SFT’s Academy. Combining our medical education forums and committees would make more efficient use of clinicians’ time. We will also be able to offer more specialist support to trainees in difficulty and colleagues who are new to the NHS. This is turn should support improved recruitment from our trainee pool into post-qualification roles.
Joint ventures and wholly owned subsidiaries
6.96 If we secure approval to move to Business Case stage we will agree our approach to existing joint ventures and YDH’s wholly owned subsidiaries. This will include how to bring together SFT’s estates and facilities colleagues (who are NHS employees) with the staff of Simply Serve Limited who are not NHS employees. It is our intention that Symphony Healthcare Services will continue to be the ‘at scale’ provider of primary care in Somerset.
How the merged Trust will address Somerset healthcare challenges
6.97 Figure 45 below sets out how the health and care challenges in Somerset (presented in paragraph 2.38) are addressed by the clinical and operating models described above.
93 Certificate of Eligibility for Specialist Registration
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Figure 45: Somerset challenges and how they will be addressed
Challenge (from paragraph 2.38) How our merger will address this challenge
Challenging demography Increase in early intervention at neighbourhood level to reduce escalation of need to emergency/crisis. This will include specialist advice from geriatricians to neighbourhood teams so older people can receive care and support in their own home. Inequalities Use of population health approach to identify health inequalities and those at risk of deteriorating health. More care provided closer to home to address inequity of access. Skills sharing between mental health and physical health clinicians to support parity of esteem. Pressure on MH services Continued development of system-wide Open Mental Health service to provide early care for people with mental health issues. As one entity it will be easier to ensure adequate attention and resources are directed to mental health services. Rising demand Development of community-based care pathways to re-focus hospitals on acute/emergency patients. Increased support for prevention and early intervention to reduce escalation of need. Bed-based care Increase in community-based care provided from neighbourhood hubs to reduce requirement for inpatient admission. Improved referral criteria and triage; increased availability of alternatives to hospital admission. Covid-19 Continued planning and management of the current major incident as one entity able to flex collective resources in future periods of pressure. County-wide plan for the recovery of services and tackling elective backlog. County-wide Covid rehabilitation service (see Figure 28). Workforce recruitment gaps Larger employer able to offer more attractive and flexible roles to fill and agency costs vacancies. Better career development opportunities through rotational roles and a wider portfolio of services. Better training and skills-sharing. Wider service mix creating enhanced research opportunities. Performance against Reduced ED attendances, non-elective admissions, and elective constitutional standards demand than would otherwise be the case as a result of greater investment in prevention and early intervention. Single county-wide waiting lists to make best use of combined elective capacity. Financial pressures See Chapter 8 Savings arising from pathway changes, reduced reliance on bed- based care. Savings from rationalisation of support services.
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7. Expected benefits of merger
Summary of key messages This chapter sets out the expected clinical and corporate non-financial benefits of the proposed merger. The financial benefits of merger are set out in Chapter 8. Key messages include: The proposed merger will create an organisation with the scale and reach to implement new care models that will improve care and offer better value for money. Underpinned by our combined resources and population health analytics, our clinical strategy will drive improved population health, better individual health outcomes and improved patient experience. We will be able to manage better the rising demand for services through reduced elective demand and non-elective attendances and admissions, than would otherwise be the case without merger. Merger will support improved patient care through higher quality and more sustainable integrated services, reduction in health inequalities and unwarranted variation of care. Greater focus on prevention and earlier intervention will drive improved health outcomes, safer care and reduced exposure to hospital-acquired harm. Person-centred care will improve patient and carer experience, as will support to help people develop the confidence and skills to self-manage their condition, shorter waiting times and more care being provided closer to home. Our colleagues will benefit through improved wellbeing and motivation from working in improved services, broader career opportunities, an enhanced training offer and a richer research environment. Our enhanced colleague offer will improve recruitment and reduce our reliance on temporary staff. The merged Trust will be more resilient during times of pressure (Covid or otherwise) due to its larger colleague base and increased infrastructure resources. We will be able to make better use of resources by removing duplicate activity in clinical support and corporate services, take advantage of economies of scale and make more efficient use of our combined estates. Streamlined patient pathways and county-wide waiting lists will help us improve Somerset’s performance against NHS constitutional standards. As a merged Trust we will be in a better position to work with our partners to implement a population health approach and gain deeper insight into the health needs of the people we serve. We will also be better able to contribute to the social and economic development of Somerset. Benefits to our system partners include: o Greater support to primary care by enhancing their knowledge of complex conditions, and clearer pathways which reduces administrative burden on GPs o Benefits for Somerset County Council from lower social care costs and reduced use of care home placements o Benefits for SWAST from fewer ambulance conveyances to hospital o Enhanced capability and confidence of local voluntary sector organisations in providing prevention and early intervention support We are applying Benefits Realisation Management (an evidence-based, industry standard tool) to the transaction itself and to all integration projects to help identify and measure the realisation of integration benefits.
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7.1 The proposed merger will create an organisation with the scale and reach to implement new care models that will improve the care people receive and present better value for money. By bringing together our combined trust resources, and informed by population health analytics, our clinical strategy will drive improved population health, better individual health outcomes and improved patient experience.
Expected benefits of clinical strategy
7.2 We will be able to manage better the rising demand for services through reduced ED attendances, non-elective admissions, and elective demand than would otherwise be the case without merger. The strategy will generate savings through shorter length of stay, streamlined patient pathways and lower spend on agency and locum staff. It will also help us improve colleague well-being and tackle our recruitment challenges.
7.3 We have not been able to set any expected benefits around health outcomes as insufficient health outcome data is collected in Somerset to support baselining and monitoring of benefits framed in that way. The Somerset system acknowledges the need to collect health outcome data and is considering how best to do this.
Patient benefits
Improvements in quality and patient care 7.4 Merger, and the implementation of our clinical strategy, will support improved patient care in the following ways:
provision of higher quality and more sustainable acute services across the county; integration of county-wide acute, community, mental health and primary care services to provide holistic, proactive care reduction in unwarranted variation in clinical practice and outcomes through county-wide services; reduction of health inequalities, with fair and equitable access across sites and, in some cases, shorter waiting times; focus on prevention and earlier intervention leading to improved health outcomes, safer care and reduced exposure to hospital-acquired harm; fewer emergency attendances which convert to admissions (than would otherwise be the case), especially long stay admissions; greater focus on patient empowerment and supported self-management; improved decision-making (including investment decisions) driven by Somerset population data sets and population health analytics sharing of best practice and clinically-led improvements to drive continuous improvement in service quality and clinical outcomes.
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Improved patient and carer experience 7.5 The clinical strategy will support improved patient and carer experience in the following ways:
shorter time waiting for the right care - less time in pain, feeling anxious or inconvenienced by injury – and more time to do what matters to the patient; more care provided closer to home - reduced travel time and cost, time off work and cost of childcare; care in line with what matters to the patient and their carers greater patient self-efficacy, confidence and skills to self-manage assistance to remain at home and maintain independence enhanced support for carers patient pathways that are clear and easy to navigate no unnecessary appointments that are not clinically justified better joined up working with other health and care providers to improve holistic care hospital estates which better support recovery and wellbeing.
Benefits to the merged Trust
Resilience and use of resources 7.6 The pandemic has shown the benefits of working together. The proposed merger will boost our resilience by improving our ability to flex colleague and infrastructure resources to respond to temporary or seasonal pressures. It will help us address present and anticipated workforce issues and help us offer improved career pathways with more career opportunities. Merger would also enable us to join up our emergency planning and response teams so we are better able to respond when needed.
7.7 As a merged Trust we will be able to make more effective use of our resources by removing duplicate activity in clinical support and corporate services and redirecting the released resources elsewhere. We will be able to make more efficient use of our combined estates. We will also be able to take advantage of economies of scale, eg discounts on larger bulk orders of consumables including medicines.
Performance benefits 7.8 The planned changes will help us improve Somerset’s performance against NHS constitution standards. Appendix 4 describes both Trusts’ recent performance against national standards. Figure 46 below shows the elements of the clinical strategy that will support improved performance against national standards.
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Figure 46: drivers of improved performance
National Drivers of improved position standard Referral to Streamlined patient pathways Treatment and 52 Single county-wide services to make best use of elective week waiters capacity Fewer referrals to acute services as a result of more care in neighbourhoods, better support to GPs, and triage of referrals Fewer unnecessary follow-up appointments and Did Not Attends from increased self-management and PIFU Fewer interventions required to address complications arising from delays 4-hour A&E Neighbourhood prevention and early intervention support which reduces risk of care needs escalating to crisis or emergency Increased support to carers to spot the early signs of deterioration so action can be taken before crisis or emergency is reached Ongoing admissions avoidance projects eg Rapid Response Improved medicines management reducing incidence of adverse drug reactions and falls Advice and guidance via MDTs to support the care of complex patients in the community Diagnostics Fewer repeated diagnostics through improved pathways, triage and trusted assessment Shared use of capacity to meet peaks in demand and improved use of community diagnostics capacity Fewer interventions of limited diagnostic capacity Cancer 62 days Pathway reviews Single county-wide services to make best use of elective capacity
7.9 The merged Trust’s stronger links between mental health and physical health teams at both acute sites will support quicker identification and referral of people who need mental health care thereby supporting continued achievement of mental health access standards.
Colleague benefits
7.10 Being a single organisation will help us tackle the recruitment challenges in Somerset. We will be able to offer improved career opportunities to existing and potential colleagues, an enhanced training offer and a richer research environment. Bringing our services together has made it easier to recruit to hard-to-fill posts (eg urology consultant, see paragraph 3.40) as a result of roles being more attractive.
7.11 We also believe that the clinical strategy for the merged Trust will increase colleague satisfaction and motivation. Experience from a trial in Scotland of the Nuka model of
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person-centred care94 showed staff satisfaction increased significantly due to working with a more satisfying clinical model, see Figure 47.
Figure 47: staff satisfaction following trial of Nuka model in Scotland
7.12 The expected benefits of the merger for colleagues include:
improved colleague satisfaction from working in a streamlined, patient-centred service; greater opportunities for career development and research arising from being a larger Trust with higher patient volumes and offering a wider range of services; broader opportunities for training and professional development through rotational posts in different care settings, a wider training offer and professional qualifications provided in association with the University Centre Somerset; increased skills and confidence in caring for people in different cohorts, e.g. with mental health issues in acute settings, or physical health issues in mental health settings; a more comprehensive wellbeing offer; improved recruitment arising from more attractive posts and greater opportunities for flexible working; increased team resilience and less risk of colleague burnout; and wider options for succession planning.
7.13 We expect our enhanced colleague offer, as set out above, will help improve our recruitment rates and thereby reduce our reliance on agency and locum staff.
94 The Nuka model of care involves multidisciplinary teams providing integrated health and care services in primary care and community settings which are closely co-ordinated with other health and care services, and services that support wider determinants of health such as education.
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Benefits to Somerset health and care system
7.14 Once merged we will be in a better position to work with our partners to implement a population health approach to gain deeper insight into the health needs of the people we serve. This will benefit not only the merged Trust but our system partners as well.
7.15 In addition to financial benefits (set out in Chapter 8), we expect implementation of the clinical strategy will benefit the wider Somerset system in the following ways:
Greater support to primary care via: o earlier intervention and support for self-management; o clearer pathways and streamlined referral processes which remove some steps for GPs; o specialist advice and guidance to GPs to support care of individual patients; and o multi-disciplinary team meetings to build skills in managing complex long terms conditions e.g. Diabetes. Benefits for Somerset County Council in the form of: o lower social care costs (compared to the position without merger) from intervening earlier, which maintains patient function and means less social care support is required; and o reduced use of care home placements Benefits for SWAST95 from earlier intervention which reduces cases that escalate to an emergency, meaning fewer ambulance conveyances to hospital. Enhanced capability and confidence of local voluntary sector organisations in providing prevention and early intervention support as a result of improved advice and guidance from clinical colleagues.
Social, economic and environmental benefits 7.16 The merged Trust will contribute to the social and economic development of Somerset in the following ways. Our clinical strategy means people will take less time off work because of ill health or to attend healthcare appointments. Fewer healthcare related journeys will have environmental and health benefits, and lead to a lower Somerset carbon footprint.
7.17 As a significant local employer, the merged Trust will provide attractive jobs and apprenticeships with good career prospects. Our combined apprenticeships programme will support the sustainability of the University Centre Somerset programme, which helps retain young people in the county. We will also continue to offer volunteering opportunities which help people develop new skills and remain socially engaged.
7.18 The merged Trust will be a major owner of estates, and our ongoing estates redevelopment programmes (YDH2030 and Musgrove2030) will create local
95 South West Ambulance Service NHS Foundation Trust.
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employment and contribute to economic development and support ongoing regeneration work in Somerset96.
Approach to benefits realisation
7.19 We are applying our joint Improvement team’s Benefits Realisation Management (BRM) approach to the transaction itself and to all integration projects, clinical and corporate. BRM is an evidence-based, industry standard tool.
7.20 As described in Chapter 6, the combined Improvement Team will operate across the merged Trust and will support project teams to use BRM to identify and measure the realisation of integration benefits and ensure projects are consistently managed and reported on.
7.21 If we receive approval to move to Business Case, we will provide more detail on our proposed approach to the realisation of both clinical and non-clinical benefits.
96 https://www.somerset.gov.uk/business-and-economy/regeneration/
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8. Finance
Summary of key messages
This chapter sets out the individual financial performance of SFT and YDH, and the expected incremental costs and savings of the proposed merger. Key messages include:
SFT was created on 1 April 2020 when Somerset Partnership NHS Foundation Trust (SPFT) and Taunton and Somerset NHS Foundation Trust (TSFT) merged. SPFT delivered surpluses in 2018/19 and 2019/20 of £1.8 million and £0.8 million respectively. TSFT’s performance worsened from a £16.8 million deficit in 2018/19 to a £17.4 million deficit in 2019/20 (all figures before revaluations and PSF). YDH’s deficit reduced from £21.3 million in 2018/19 to £19.5 million in 2019/20 (before revaluations and PSF). Both Trusts are forecasting a breakeven outturn for 2020/21. However, these positions include national support funding and do not reflect the Trusts’ underlying financial positions. Structural drivers of the system deficit include sub-scale services arising from rurality, and systemic staff recruitment and retention challenges. There is also evidence to suggest that the bed-based model of community services rather than a more integrated and responsive community-based model increases system costs. Without transformational change to the way health and care services are provided, the system deficit position will continue to deteriorate, and the scale of financial challenge will increase. Although merger will help improve the merged Trust and system position it will not, on its own, eradicate the deficit. Savings will come from the development of new integrated pathways of care, reduced length of stay in community and acute beds and better demand management from teams working in a clinically and operationally aligned way. In addition, we expect support services cash releasing savings. We will do further work at business case stage to estimate transformation costs. Uncertainty about the future financial regime presents a significant risk to the detailed financial model that will be required at Business Case stage. The challenging system financial position may also constrain our ability to invest in the change necessary to deliver future benefits, for example where there is a time lag between costs incurred and savings delivery. The merger creates the opportunity for a strengthened financial strategy and enhanced ability to deliver it through increased financial and operational expertise, capacity and resilience.
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SFT financial performance
8.1 SFT was formed on 1 April 2020 when Somerset Partnership NHS Foundation Trust (SPFT) and Taunton and Somerset NHS Foundation Trust (TSFT) merged. The recent historical performance of SFT’s legacy Trusts is presented in Figure 48 below.
SPFT historical performance 8.2 As shown in Figure 48, SPFT’s financial performance was stable between 2018/19 and 2019/20, with a small reduction in surplus before revaluations and Provider Sustainability Funding (PSF), reducing to £0.8 million (0.4 per cent of operational expenditure) in 2019/20.
8.3 The surplus for each of the years is driven by the requirement from NHSEI to achieve centrally set control totals. In 2019/20 SPFT achieved its control total and received £2.2 million of PSF. In 2019/20 The Trust delivered CIP of £6.2 million (c.3.3 per cent of operational expenditure), with 34 per cent of CIP being delivered non-recurrently.
TSFT historical performance 8.4 As shown in Figure 48, the financial performance of TSFT worsened from a £16.8 million deficit (5.2 per cent of operational expenditure) before revaluations and PSF in 2018/19 to a deficit of £17.4 million (4.7 per cent of operational expenditure) in 2019/20.
8.5 The main driver for the deterioration from 2018/19 to 2019/20 was a shortfall in CIPs delivery and higher than planned non-recurrent savings which impacted on the underlying position moving forward. Further contributing factors were that, in 2019/20 the Trust incurred additional costs relating to nationally awarded pay increases and additional staffing costs associated with workforce transformation and managing increased demand, particularly for emergency admissions and winter pressures.
8.6 In 2019/20 The Trust delivered CIP of £9.0 million (c.2.5 per cent of operational expenditure), with 41 per cent being delivered non-recurrently.
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Figure 48: SFT past financial performance (legacy Trusts)
2018/19 2019/20 SPFT TSFT SPFT TSFT
actual actual actual actual £000 £000 £000 £000 Clinical income 168,200 283,132 175,402 313,923 Other income 12,489 39,374 11,293 54,857 Pay (127,695) (200,276) (133,720) (228,477) Non-pay (61,608) (131,935) (47,409) (139,903) Operating Surplus/(Deficit) (8,614) (9,705) 5,566 400 Gain/(loss) on disposal of fixed assets (76) (4) 7 0 Net finance costs 82 (1,552) 154 (1,764) PDC dividend (3,051) (3,859) (2,473) (3,649) Share of profit / (loss) of associates / joint 236 184 ventures Retained Surplus/(Deficit) (11,659) (14,884) 3,254 (4,829) Revaluation (exceptional) 17,542 4,271 (144) 5,811 Provider Sustainability Funding (4,110) (6,223) (2,308) (18,372) Retained Surplus/(Deficit) before 1,773 (16,836) 802 (17,390) exceptional items & STF/PSF
Plan (before STF/PSF) 1,724 (9,102) 334 (17,576) Variance from plan 49 (7,734) 468 186
SFT current performance
8.7 SFT’s forecast outturn for 2020/21 is breakeven, which is £14.7 million favourable to the revised plan submitted in October 2020, see Figure 49. The revised plan was for a £14.7 million deficit based on the initial estimated value of the annual leave provision and a shortfall in non-NHS income both of which have subsequently been funded by NHSEI. Whilst a breakeven position is forecast for 2020/21 there is an underlying financial deficit for the Trust.
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Figure 49: SFT current financial performance – statement of combined income and expenditure
2020/21 Variation SFT Forecast Plan from plan outturn Fav / (Adv) £000 £000 £000 Clinical income 489,042 488,671 371 Other income 88,589 60,200 28,389 Pay (383,041) (375,724) (7,317) Non-pay (186,821) (180,140) (6,681) Operating Surplus/(Deficit) 7,769 (6,993) 14,762 Gain/(loss) on disposal of fixed assets (552) (552) 0 Net finance costs (1,773) (1,561) (212) PDC dividend (5,557) (6,313) 756 Share of profit / (loss) of associates / joint 22 15 7 ventures Retained Surplus/(Deficit) -91 (15,404) 15,313 Revaluation (exceptional) 91 754 (663)
Retained Surplus/(Deficit) on control 0 (14,650) 14,650 total basis
8.8 SFT’s balance sheet as at 1 April 2020, 31 January 2021 and forecast as at 31 March 2021 is at Figure 50 below.
8.9 SFT’s balance sheet position has improved from 1 April 2020 to 31 March 2021 due to reforms to the NHS cash regime whereby DHSC interim revenue and capital loans in place at 31 March 2020 were extinguished and replaced with the issue of Public Dividend Capital (PDC) to allow the repayment.
8.10 Cash shows a significant increase at 31 January 2021 due to the changes to the NHS cash regime for 2020/21 with income being received in advance. However, this will unwind before the end of the financial year and there will be a reduction in both Cash and Current Liabilities as can be seen in the 31 March 2021 values.
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Figure 50: SFT statement of financial position as at 1/4/20, 31/1/21 and forecast at 31/3/21
Forecast As at 1/4/20 As at 31/1/21 SFT outturn 31/3/21 £000 £000 £000 Non-current assets 286,436 301,540 319,391 Cash 32,570 94,747 39,994 Current assets 40,236 24,651 24,935 Current liabilities (90,306) (126,385) (78,459) Assets less current liabilities 268,936 294,553 305,861 Non-current liabilities (29,046) (29,322) (32,662) Total assets employed 239,890 265,231 273,199 Financed by PDC 127,062 162,828 175,795 Revaluation reserve 65,560 65,560 65,560 Income & expenditure reserve 47,268 36,843 31,844 Total taxpayer’s equity 239,890 265,231 273,199
YDH financial performance
8.11 The historical and current performance for the YDH Group is set out in Figure 51 below. This position includes the Trust’s wholly owned subsidiaries. Yeovil District Hospital has two main wholly owned subsidiary companies, with a third Yeovil Property Operating Company Limited having minimal transactions (see paragraph 2.4):
Simply Serve Limited (SSL) provides estates and facilities management and other support services to the Trust and commenced operations in February 2018. Its purpose is to enhance quality and cost effectiveness of services, improve the recruitment and retention of key staff groups, and generate third party income. SSL has a strong financial position and contributes a surplus to the Group position. Symphony Healthcare Services Limited (SHS) provides primary care general practice services across 11 practices as at April 2021, with a twelfth practice due to join in July 2021. It was initially funded through the national Vanguard programme but is now funded through the primary care funding held by the CCG. SHS makes a significant financial contribution to the system through improving primary care efficiency and productivity, delivering turnaround of challenged practices, and implementing new approaches which reduce demand on secondary care. However, SHS itself is in a deficit position.
8.12 As shown in Figure 51, YDH’s financial performance was stable between 2018/19 and 2019/20, with a reduction in deficit before revaluations and PSF from £21.3 million (12.5 per cent of operational expenditure) in 2018/19 to £19.5 million (10.0 per cent of operational expenditure) in 2019/20.
8.13 The single largest element of the Trust’s deficit is the structural costs arising from diseconomies of scale due to the size and rurality of the Trust. Other factors are the deficit position of SHS and a degree of excess operational costs.
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8.14 In 2019/20 The Trust delivered CIP of £5.2 million (c.2.7 per cent of operational expenditure), with 49 per cent being delivered non-recurrently.
8.15 The forecast outturn for 2020/21 is breakeven, see Figure 51. This is £0.6 million favourable to the revised plan submitted in October 2020. The revised plan was for a £0.6 million deficit based on the initial estimated value of the annual leave provision, which was subsequently funded by NHSEI. Whilst there is a breakeven position in 2020/21 there is an underlying financial deficit for the Trust.
Figure 51: YDH financial performance – statement of combined income and expenditure
2018/19 2019/20 2020/21 Forecast Variation YDH Actual Actual Plan outturn from plan £000 £000 £000 £000 £000 Clinical income 131,983 152,449 168,718 171,368 (2,650) Other income 21,324 42,430 39,443 33,527 5,916 Pay (107,944) (121,916) (134,864) (134,033) (831) Non-pay (62,668) (71,504) (71,118) (68,874) (2,244) Operating (17,305) 1,459 2,179 1,988 191 Surplus/(Deficit) Gain/(loss) on disposal of 744 (91) (59) (16) (43) fixed assets Net finance costs (1,533) (1,469) (114) (54) (60) PDC dividend 0 0 (1,402) (2,100) 698 Share of profit / (loss) of (72) 0 0 0 0 associates / joint ventures Corporation Tax (109) 28 (604) (405) (199) Retained Surplus/(Deficit) (18,275) (73) 0 (587) 587 Revaluation (exceptional) 101 84 0 0 0 Provider Sustainability (3,142) (19,479) Funding Retained Surplus/(Deficit) before exceptional items (21,316) (19,468) & STF/PSF Retained Surplus/(Deficit) 0 (587) 587 on control total basis Plan (before STF/PSF) (19,363) (18,835) Variance from plan (1,953) (633)
8.16 YDH’s balance sheet as at 31 March 2020, 31 January 2021 and forecast as at 31 March 2021 is at Figure 52 below.
8.17 YDH’s balance sheet position has improved from 2019/20 to the forecast for 31 March 2021 due to reforms to the NHS cash regime whereby DHSC interim revenue and capital loans in place at 31 March 2020 were extinguished and replaced with the issue of Public Dividend Capital (PDC) to allow the repayment. This accounts for the move from negative taxpayer’s equity of £17.2 million to positive taxpayer’s equity of £76 million.
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8.18 Cash shows a significant increase at 31 January 2021, due to the changes to the NHS cash regime for 2020/21 with income being received in advance. However, this will unwind before the end of the financial year and there will be a reduction in both Cash and Current Liabilities as can be seen in the 31 March 2021 values.
Figure 52: YDH statement of financial position as at 31/3/20, 31/1/21 and forecast at 31/3/21
Forecast YDH As at 31/3/20 As at 31/1/21 outturn as at £000 £000 31/3/21 £000 Non-current assets 70,167 70,641 79,372 Cash 37,335 22,118 Current assets 31,680 11,544 9,090 Current liabilities (115,402) (42,735) (30,353) Assets less current liabilities (13,554) 76,785 80,227 Non-current liabilities (3,620) (3,994) (4,228) Total assets employed (17,174) 72,791 75,999 Financed by PDC 44,592 134,442 137,782 Revaluation reserve 13,371 13,371 13,371 Income & expenditure reserve (75,137) (75,022) (75,154) Charitable funds reserve Total taxpayer’s equity (17,174) 72,791 75,999
Historical System Performance and ICS Context
Drivers of the Somerset deficit 8.19 The Somerset system is in significant underlying deficit. Without transformational change to the way health and care services are provided, the deficit position of the system and of individual provider and commissioner partners will continue to deteriorate and the scale of financial challenge will increase. Tackling the system deficit will require action by the whole Somerset system. Although merger will help improve the system position it will not, on its own, eradicate the deficit.
8.20 The system works collectively to manage the financial position and decisions focus on reducing cost and increasing efficient use of resources, rather than moving the deficit between commissioners and providers. There is a single financial framework in place which has been developed through the Somerset Directors of Finance group.
=
Projected incremental merger savings
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8.21 Our clinical model supports prevention, early intervention and will reduce emergency demand (compared to forecast) and outpatient activity. These changes will release pressure not only on the merged Trust but also on our system partners. The Somerset system will benefit financially through reduced spend on acute activity (mitigation of acute growth), with a proportion of this saving re-invested in other parts of the system to enable and deliver the new models of care. Any marginal benefit between the acute activity avoided and the re-investment cost is assumed to correct some of the current funding shortfalls in the Trusts, helping to restore financial balance.
8.22 The creation of a single, larger organisation will improve our ability to move investment flexibly along pathways and between services to support the changes envisaged in the clinical strategy. We will also be better able to manage timing differences between investments and the full achievement of related savings.
8.23 We believe our system partners will reap direct financial benefits from our clinical model e.g. through more efficient standardised patient pathways, reduced pressure on GPs, fewer ambulance conveyances and reduced social care costs. These savings are expected to be largely non-cash releasing and further work with partners will be undertaken at Business Case stage to understand these in more detail.
Clinical savings
8.24 As part of the merger we expect to build on the efficiencies and cost savings being targeted following the creation of SFT through the transformation of a number of clinical services. We will extend the clinical model that is less reliant on costly bed- based care to ensure the benefits of integrated hospital and community services extend to YDH services and drive out any additional savings through the adoption of a county-wide approach. In the context of rising demand we are unlikely to be able to reduce the absolute number of acute beds, however we believe we can make lower use of bed-based care than would be the case without merger.
8.25 Similarly we would expect to build on the benefits of other initiatives which could be extended across both organisations, such as the closer working with primary care fostered by the development of SHS, to transform services and pathways, contain demand and maximise gains.
8.26 Evidence suggests97 that whilst reducing hospital activity and increasing community- based care does not save money in all circumstances, the most positive evidence for cost saving comes from changes to services which are targeted to particular groups of patients e.g. improved end of life care in the community and condition-specific
97 BMJ March 2017, and Nuffield Trust “Shifting the Balance of Care” 2017.
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rehabilitation, and we will focus on areas such as these as we develop our detailed plans.
8.27 The expected timescale for making changes to clinical services and securing the associated savings is two-three years, and in some cases will be longer.
8.28 The key clinical savings will come from the development of new integrated pathways of care, building on initial integration work to date. Financial savings will come from reduced length of stay in community and acute beds, and better demand management from teams working in a clinically and operationally aligned way. Improved use of resources at the most cost-effective point in the patient pathway will increase productivity, reduce unit cost and allow for growth to be accommodated. Although a level of savings could potentially be achieved purely through more collaborative working, the alignment of priorities and singular focus on the delivery of integrated care models within a single organisation is more likely to ensure delivery of the identified opportunities in a rapid, cost-efficient and sustainable way.
8.29 Both Trusts are currently developing Patient-Level Information and Costing Systems which report the cost of events relating to individual patient care. This data will support planning and enable us to monitor and report the savings delivered by clinical integration.
8.30 Some of the expected savings will accrue to the combined organisation and some will accrue to other parts of the Somerset health and care system. In the interests of patients and taxpayers we are taking a system-wide view and, subject to discussions with partners, we are exploring all savings opportunities regardless of the organisation in which the financial benefits may take effect.
Support services savings 8.31 It is expected that the most significant savings will be made in governance, including reduced Board costs, IT, HR, finance and procurement with reductions to WTEs and a consolidation/rationalisation of processes, systems and licences. At Business Case stage a full review of the opportunities in estates will also be undertaken but there was a significant efficiency included in the SFT merger which needs to be taken into consideration.
Transaction and transformation costs
8.32 We propose to cover the full cost of the proposed merger from the two Trusts’ budgets and are seeking to keep costs low by minimising use of external advisers and using in- house resources as far as possible. This approach has the additional advantage of ensuring ownership and retention of the developing thinking and planning. Existing operational and transformation teams will be used to supplement the additional resource.
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Risks
8.33 The current NHS financial regime presents a significant risk to the detailed financial model that will be required for the Business Case due to the lack of certainty about the future framework and funding flows. To some extent this can be mitigated through a focus on incremental costs and savings.
8.34 The challenging system financial position may constrain ability to invest in the change necessary to deliver future benefits, for example where there is a time lag between costs incurred and savings delivery or where there is an element of risk or uncertainty as to outcomes. This can be mitigated through continued system commitment to longer-term sustainability and robust change management.
8.35 The Trusts’ capital programmes, Musgrove2030 and YDH 2030 will be significant enablers to ensure the clinical environment supports the new clinical strategy. These are large scale projects with a dependency on external decision and approval processes. However, the proposed merger does not depend on the delivery of these capital programmes.
Finance and capital strategy
8.36 The merger will create the opportunity for a strengthened financial strategy and enhanced ability to deliver that strategy through increased financial and operational expertise, capacity and resilience. We would expect the key features of a future financial strategy to include:
A strong focus on achieving best value for our available resources, optimising quality and cost Structured shifting of investment along pathways and across patient cohorts to where it has maximum impact on improving outcomes Evidence-driven decision-making, with a framework for taking considered risks in pursuit of the greatest benefit Strong financial governance and control of avoidable costs.
8.37 A single approach to capital will build on the benefits already being demonstrated by the aligned approach to the 2030 capital programmes, maximising the opportunity to secure capital funding for developments to enable service change.
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9. Transaction execution
Summary of key messages
In this chapter we outline our plans to deliver the proposed merger. Key messages include: The proposed transaction is a merger of equals, with the two Trusts voluntarily coming together for the benefit of the people they serve. For cost and time reasons the Boards’ preferred legal route is merger by acquisition, where SFT acquires YDH (using s.56a of the NHS Act 2006). Our intended ‘go-live’ date for the merger is 1 April 2022. We have developed a programme plan to guide delivery of our merger which involves submitting the Business Case to NHSEI for review in November 2021. At the point of transaction, the merged Trust will have a reconstituted Board with Non-Executive Directors drawn from both legacy Trusts. We will convene a group involving governors from both Trusts to review the Constitution for the merged organisation. Key decisions relating to the proposed merger are taken by both Trust Boards. A merger Programme board consisting of a subset of executives from both Trusts has oversight of our merger and integration planning. We will use in-house resources to deliver the transaction as far as possible, to maintain ownership, retain skills, and keep costs down. However, we will procure specialist legal and other consultancy support to help prepare some aspects of the Business Case. We are applying project management methodology to the transaction itself and to all our integration projects. We will use our internal expertise in benefits realisation to identify and quantify the tangible and intangible benefits of merger and ensure integration projects deliver their planned benefits. We are maintaining an integration risk register to help manage key risks related to the proposed transaction. We commissioned PwC and Bevan Brittan to carry out all initial Due Diligence on our behalf, which they conducted according to a limited scope owing to pandemic constraints. The Trusts consider a merger notification to the CMA is not required as the transaction does not appear to raise the prospect of a substantial lessening of competition, and in any event is likely to be exempt from review by the time the transaction completes. We have begun to engage with colleagues and public and patient representatives about our plans. We have developed a communications and engagement plan to support the proposed merger.
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Legal form of transaction
9.1 The proposed transaction is a merger of equals, with the two Trusts voluntarily coming together for the benefit of the people they serve. However, the Boards are mindful that effecting the transaction through statutory merger (s.56 of the NHS Act 2006) is slower and more expensive than if one Trust were to legally acquire the other (using s.56a of the Act).
9.2 After considering the merits and demerits of the available legal routes (and after taking legal advice) the two Trust Boards have agreed that their preferred legal route is merger by acquisition, where SFT acquires YDH. This choice was made on the grounds of cost and time, as the expected cost of transferring YDH’s assets to SFT is lower than transferring SFT’s assets to YDH, largely because of the number of properties involved.
Merged Trust’s name
9.3 If we secure approval to move to Business Case stage, the two Boards will decide at that stage about the name of the merged Trust, informed by the views of colleagues, Governors, partner organisations and other stakeholders such as MPs. We will ensure we comply with the NHS naming conventions.
Planning for Board and Council composition of merged Trust
Board
9.4 Currently each Trust maintains its own separate Board. The SFT Board has 8 Non- Executive Directors (NEDs), 7 voting Executives and 2 non-voting Executives. The YDH Board has 5 Non-Executives, 4 voting Executives and 3 non-voting Executives. In addition, in 2018, two of SFT’s Non-Executive Directors began attending YDH Board meetings, and in early 2019 one of YDH’s Non-Executive Directors began attending SFT Board meetings (all with non-voting status) to aid collaboration and support work on the proposed merger.98
9.5 Since signing the MoU the two Boards have held four joint ‘Board to Board’ meetings. The two executive teams also meet regularly to discuss collaboration and matters relating to the merger.
9.6 The proposed merged entity will cover the whole of Somerset and provide a very broad range of mental health, community, acute and primary care services. We are mindful that the Board of the merged entity needs to have the necessary skills and experience to enable it to provide effective leadership and oversight of the enlarged Trust. At the point of transaction, we intend the merged Trust to have a reconstituted Board with Non-Executive Directors drawn from both legacy Trusts. Short biographies of the two Trusts’ Board members are provided at Appendix 7.
98 Barbara Clift and Stephen Harrison from SFT attend the YDH Board, while Graham Hughes from YDH attends the SFT Board.
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9.7 During 2021/22, we will move to holding Board meetings in common where the business is shared across the two Trusts. This will be subject to the appointment of a single executive team. Following the departure of YDH’s Chief Operating Officer in December 2020, the two Boards agreed that SFT’s two Chief Operating Officers would become members of the YDH Board and work across the county.99 YDH has appointed a Director of Operations to work at the YDH site to support this arrangement. Until a shared executive team is in post, we will recruit to any further executive vacancies as shared posts, unless there are compelling grounds to do otherwise.
Board sub-committees
9.8 During 2021/22, we plan to align the Terms of Reference of our sub-committees and establish committees in common to support the review of areas of activity that are common to both Trusts. The Non-Executive Chairs and executives from key Board sub-committees already attend each other’s meetings to observe and contribute to discussions, which will help this transition and aid mutual sharing of good practice. Collaboration between the Trusts’ sub-committees is already helping to drive alignment: the audit committees are ensuring the internal and external auditors are common to both Trusts, and committee members routinely asked about the position or impact of an issue at the other Trust.
Governors
9.9 The Lead Governors of both Trusts meet regularly to share ideas and discuss the implications for Governors of the proposed merger. If we receive approval to move to Business Case we will establish a process to review the public and staff constituencies and make-up of the Council of Governors for the merged Trust, to ensure appropriate and proportionate representation across the county and beyond. If necessary, we will hold elections to the Council of Governors shortly after transaction date to fill any vacancies. We will also convene a group including Governors from both Trusts, to review and develop the Constitution for the merged organisation.
Plan to deliver transaction
9.10 We have developed an initial plan covering the period up to the merger which is provided as a supporting submission to this document. Assuming we receive the necessary approval to move to Business Case stage, we will further refine this plan during the Business Case stage.
9.11 There is a risk that merger planning could have an adverse impact on business as usual, and to manage this we have set out a timetable for merger which seeks to move at pace while also recognising that sufficient senior management time needs to be devoted to ensuring we continue to provide high quality care to our patients,
99 Matthew Bryant has been appointed Chief Operating Officer (Hospital Services) at YDH. Andy Heron has been appointed Chief Operating Officer (Mental Health, Families and Neighbourhoods) at YDH. However, as Andy is currently leading the Somerset Covid-19 vaccination programme his start date to begin supporting YDH has yet to be confirmed.
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particularly in light of the challenges thrown up by the pandemic. The fact that most SFT Board members have recent experience of an NHS transaction (from the creation of SFT) means our local capability to deliver the transaction is strong.
9.12 Key milestones set out on the transaction delivery plan are as set out in Figure 53 below. Provided we secure the necessary support and approvals from our Boards, governors, stakeholders and regulator, our intended ‘go-live’ date for the merger is 1 April 2022.
Figure 53: Key milestones in transaction delivery plan
Date Milestone May 2021 NHSEI complete review of Strategic Case and indicate whether or not proposed transaction may move to Business Case stage
May – November Trusts develop Business Case, including Long-Term Financial Model, 2021 post-transaction implementation plan, full due diligence, revised Constitution and Transaction Agreement
November 2021 Trusts submit final Business Case to NHSEI following approval from both Boards
January/February NHSEI challenge meeting with both Trust Boards 2022 March 2022 Boards formally approve transaction, confirmatory vote of both COGs, NHSEI formally grants transaction
April 2022 Trusts merge 1 April.
9.13 Further detail on the proposed timeline is included at Appendix 6. The detailed merger programme plan is provided as a supporting submission to this Case.
9.14 The draft timetable assumes there are no service changes requiring public consultation.
9.15 If the timetable were to slip this would increase costs, prolong the disruption to the Trusts while the merger process is completed and delay realisation of expected benefits. This risk and mitigations are included in the Integration risk register (see paragraph 9.27).
Outline transaction governance
9.16 We have a number of governance mechanisms to oversee progress of the proposed transaction. The two executive teams have established a Programme Board which has oversight of the overall integration of the two Trusts including the case for merger. It consists of a subset of executives from both Trusts, including the Chief Executives. This group reports to the two full executive teams of the Trusts.
9.17 Key decisions relating to the proposed merger are taken by the Trust Boards, and the Boards are provided with regular progress updates. The Councils of Governors of both Trusts are also kept regularly informed about progress.
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9.18 In the MoU signed in May 2020, the two Trusts committed to establishing a Provider Development Committee (PDC) to oversee the work programme set out the MoU, including development of the Strategic Case for merger. The PDC meets monthly and its membership consists of: the Chairs, CEOs and Deputy CEOs of the two Trusts, seven Non-Executive directors from both Trusts, the Chair of the Somerset GP Board, Leader of Somerset County Council, and a senior representative from the VCSE Forum in Somerset. We keep our partners updated with progress on the proposed merger via PDC meetings. Resources and programme management
9.19 The joint Senior Responsible Officers for merger planning are Jeremy Martin, Director of Transformation for YDH and David Shannon, Executive Director of Strategic Development and Improvement for SFT. David and Jeremy oversee the transaction Programme Management Office (PMO) which is headed by a Director of Integration who works across both Trusts.
9.20 We have used a workstream approach to develop this Strategic Case. If we receive approval to move to Business Case stage, we will require increased internal resources and external support to develop the Business Case. We will continue to use the existing workstreams, supplemented where necessary with additional resources, to develop the Business Case and aid planning for Day 1 and beyond. Each workstream has a senior responsible officer and specified work packages determined by the key deliverables. The merger workstreams are set out in Figure 54 below:
9.21 We will use in-house resources to deliver the transaction as far as possible, to maintain ownership, retain skills, and keep costs down. However, we do not have sufficient in-house capacity and capability to complete the Business Case on our own. Alongside expert legal advice we also intend to procure specialist consultancy support to help us prepare the Business Case, for example to help us develop the long-term financial model. Expected costs of the transaction are set out in Chapter 8.
9.22 We have identified an initial range of clinical and corporate integration projects (see Appendix 5), which will deliver the benefits identified in Chapter 7 for patients, colleagues, the merged entity and the wider Somerset health economy.
9.23 We are applying project management methodology to the transaction itself and to all our integration projects. Our approach ensures projects are consistently managed and reported, and all have a senior owner with agreed timelines and progress indicators. Progress on integration will be overseen by the Programme Board consisting of members of the executive teams of both Trusts.
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Figure 54: Merger workstreams
Workstream Executive lead(s) Scope at Business Case stage Clinical strategy Shelagh Meldrum, Meridith Clinical strategy design & identification of patient benefits Kane, Hayley Peters, Dan Meron Clinical service strategies for key services Development of plans to integrate acute services Integration of Pharmacy, Infection Control and Patient Experience functions Oversight of delivery of priority clinical integration projects Operating model Jonathan Higman, Peter Lewis Design and implementation of operating model for merged Trust Finance Pippa Moger, Sarah James Development of the Long-Term Financial Model Finance team support to integration projects Integration of Finance and Planning function Integration of Performance function Integration of Procurement function People & OD Mark Appleby, Develop and implement joint People strategy Shelagh Meldrum, Bel Clements Lead cultural harmonisation Colleague engagement Workforce planning TUPE transfer of staff Integration of HR functions Integration of Training and Education Functions Estates Phil Brice, David Shannon, Development of Estates strategy for merged Trust aligned Jeremy Martin with YDH2030 and Musgrove2030 Integration of Estates, Capital Planning and Facilities management functions Digital & Improvement Jeremy Martin, David Shannon Develop Digital strategy for merged Trust Digital support to clinical and corporate integration projects Integration of IT function Integration of Improvement Team Improvement team support to integration projects and transaction itself Governance (clinical Shelagh Meldrum, Develop clinical governance framework for new and corporate) Jeremy Martin, Phil Brice organisation Develop corporate governance for new organisation Plan transition to single Board and Council of Governors Prepare revised constitution Integration of clinical and corporate governance functions Integration of information governance function Integration of EPRR function Communications Simon Blackburn, Fiona Reid Colleague and stakeholder communications Communications strategy for new organisation Integration of Communications function Commercial/legal Sarah James, David Shannon Ensure smooth transfer of wholly and part-owned companies, JVs and key contracts/agreements Merger Case and Jeremy Martin, David Shannon Prepare Business case and supporting submissions Programme Prepare Post-Transaction Integration Plan including Day 1 management preparations Draft Heads of Terms and Transaction Agreement Secure independent reporting accountant opinions Coordinate Due Diligence Integration risk management Maintain, monitor and report progress against Integration Programme Plan Coordinate and support integration workstreams Coordinate programme of integration projects
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High level benefits realisation strategy
9.24 SFT has well-developed internal expertise in benefits realisation which supports the identification and quantification of tangible and intangible benefits and ensures projects deliver their planned benefits. This benefits realisation approach was used in the recent merger of TSFT and SPFT to create Somerset FT. We plan to use this benefits methodology to support the proposed merger of SFT and YDH but will incorporate enhancements to ensure its acceptance and utility for YDH colleagues.
9.25 The deployment of PowerHub, our jointly procured project management tool, will allow us efficiently to track delivery of benefits against our expected merger benefits.
9.26 Further detail on our benefits realisation methodology is provided as a supporting submission to this Strategic Case.
Risk assessment and management
9.27 We have developed an integration risk register identifying key risks related to the proposed transaction and the associated mitigations (see Figure 55 below). The full integration risk register is provided as a supporting submission to this Strategic Case.
9.28 The integration risk register is a live document which we will keep updated as we move through the merger process, including to take account of risks identified through the Due Diligence process. The integration risk register is a regular item at the YDH/SFT Programme Board meetings.
9.29 The two Trusts’ corporate risk registers are monitored by the Trust Boards and their sub-committees. Any significant risks relating to integration and the proposed transaction will be incorporated into the two corporate risk registers as necessary. Both Trusts’ corporate risk registers are provided as supporting submissions to this Strategic Case.
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Figure 55: Summary of key risks and mitigations
Key Risk related to Impact Likelihood Mitigation proposed transaction Risks to merger planning
Lack of capacity to plan 4 3 Fortnightly executive-led Programme Board to oversee adequately for merger planning; merger case is being prepared by a integration and dedicated merger PMO with joint executive SROs. undertake effective due External advisers being used to boost capacity where diligence due to Covid- needed. Many executives have experience of NHS merger 19 pandemic and/or process. winter pressures Risk remains around the merger programme, and in particular the Due Diligence because of operational pressures relating to the pandemic. We agreed a reduced scope for initial due diligence to reduce the burden on colleagues. Risks to realising benefits of merger
Optimism bias emerges 4 3 Industry standard Benefits Realisation Methodology will be when defining benefits used to identify and quantify benefits. Internal project of integration management expertise will be used to ensure planned benefits are clearly defined with realistic timeframes. Benefits will be framed by clinical and support service colleagues, rather than being centrally defined. Board level oversight and challenge will take place. Harmonising cultures 3 3 Initial conversations are underway around cultural from the two harmonisation and we will develop a joint People strategy at organisations while also Business Case stage which will include a single set of values retaining cherished local and behaviours for the merged Trust. identities Lack of support from 4 3 Close engagement with ICS partners, Governors, staff and patients, staff, CCG, or patient representatives, as per the Communications and other partners or NHSEI Engagement plan. Regular engagement with NHSEI. Financial position of 3 3 Continuing sound financial management and close working either Trust declines or with ICS partners to ensure investment where needed. distracts us from integrating services and Financial due diligence and benchmarking to identify savings making necessary opportunities. transformational changes to services External uncertainties 4 2 Continuing close liaison with NHSEI to stay sighted on about future financial developments. regime and/or developing legislation may impair our ability to proceed with merger or implement our integration plans
Legal advice sought
9.30 Both Trusts have engaged legal firm Bevan Brittan to provide legal advice and support for production of the Strategic Case. Bevan Brittan carried out the initial legal Due
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Diligence for both Trusts. They have also advised us on the potential legal routes to merger.
9.31 If we receive approval to move to Business Case stage, we would expect to take legal advice on matters including TUPE transfer of staff, the Heads of Terms and Transaction Agreement and revised constitution and, if relevant, public consultation on any significant changes to services.
Initial due diligence
9.32 Production of this Strategic Case has been carried out within a short timeframe and against the backdrop of winter and the pandemic. For this reason, the Trusts decided to outsource the initial Due Diligence to third parties. We jointly commissioned PwC to carry out all the initial Due Diligence on our behalf, with the exception of the legal Due Diligence which Bevan Brittan conducted on our behalf.
9.33 We commissioned initial due diligence based on the scopes set out in the NHSEI Transactions Guidance. The two Trust Boards agreed that the same level of initial Due Diligence would be carried out for each Trust. We agreed with PwC and Bevan Brittan that, owing to ongoing operational pressures associated with the pandemic, their work would be limited to presenting significant issues to the two Boards rather than a comprehensive due diligence exercise.
9.34 The draft reports from PwC were reviewed by the relevant executive director(s) to confirm factual accuracy prior to being presented to the Boards. The reports setting out the findings from the initial Due Diligence are provided as supporting submissions to this Strategic Case.
9.35 At Business Case stage we will carry out more detailed Due Diligence including refreshing any areas where there has been material change since the initial Due Diligence. We will continue to update our Due Diligence right up until the proposed merger receives final approval.
Competition analysis
9.36 In discussion with NHSEI100, the Trusts considered whether a merger notification to the Competition and Markets Authority (CMA) would be required. Currently, the CMA would have jurisdiction to review the proposed transaction. The 2021 Health White Paper (see paragraph 3.38)101 indicates a desire to exempt NHS trusts and foundation trusts from competition merger review, given the increasing importance of collaboration.
9.37 NHSEI have advised that if the Health and Care Bill is passed on the envisaged legislative timetable, and if the scope of the relevant provision does not materially change, it is likely that our planned transaction would be exempt from merger review by the planned completion date. However, this will be subject to the timetable and scope of the legislation proceeding as currently planned. The Trusts therefore
100 Email from Zoe Fiander, NHSEI, 16 March 2021. 101 https://www.gov.uk/government/publications/working-together-to-improve-health-and-social-care-for-all
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considered whether there would be any competition risk, in the event that the legislation does not pass or does not exempt this type of transaction. The Trusts also note that notification is not a requirement under the Enterprise Act 2002, and it is open to the CMA, if it retains jurisdiction at the relevant time, to call the merger in within 4 months of the transaction.102
9.38 In recent years there have been important developments in the competition assessment of NHS mergers. In its recent decision on the Bournemouth/Poole transaction,103 the CMA found that the transaction would not be expected to lead to a substantial lessening of competition. Key factors that led to this conclusion were:
challenges faced by NHS providers, including significant growth in demand for services, financial pressures and capacity constraints. The CMA found that “the NHS across England is taking a collaborative approach in response to these constraints and, as a result, competition between acute providers is typically limited.” implementation of key national policies contained in the NHS Long Term Plan, the Five Year Forward View, local Sustainability and Transformation Partnerships, and the introduction of control totals. The CMA noted that the focus of national policy is on collaboration and integration across providers the use of block contracts by the Trusts’ primary commissioner in that case the move to integrated care systems, and the introduction of financial risk sharing mechanisms within systems, including (for example) the linkage of performance incentive payments to system performance.
9.39 NHSEI indicated that if similar factors are present in this case, it would be unlikely that the CMA would seek to carry out an investigation. In discussion with NHSEI the Trusts and their legal advisers have considered whether similar factors are present in this transaction and note that:
The Contracts and payment guidance October 2020-March 2021 published in September 2020 sets out the current expectations for the remainder of the 2020/21 contract year, including the assumptions around block contracts and requirements for systems to work together on financial targets.104 The national policy direction continues to focus on collaboration rather than competition and this focus is further strengthened by the 2021 Health White Paper which proposes to create ICS statutory bodies, and to impose a formal duty to collaborate on all NHS bodies and local authorities. The emphasis on system collaboration was also clear in the operational planning guidance issued on 25 March 2021. The Trusts face similar challenges to those outlined above in terms of growth in demand, financial pressures and capacity constraints, and Covid has exacerbated the situation. Both Trusts have been on a block contract with Somerset CCG, the primary commissioner since 2018/19. A number of capacity sharing arrangements have been put in place in recent years, most recently for Ophthalmology services.
102 S.24 of the Enterprise Act 2002. 103 https://assets.publishing.service.gov.uk/media/5eb2dc08e90e070835525d24/Poole_Bournemouth_full_text_decision_CMA.pdf 104 https://www.england.nhs.uk/wp-content/uploads/2020/09/C0768-finance-guidance-with-annex-3-added-23-september-2020-.pdf
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9.40 One factor which differentiates this transaction from previous trust mergers is that both Trusts employ GPs on a salaried model.105 However, these services combined account for only around 19 per cent of patients in Somerset106. The model also has benefits, as without the Foundation Trusts providing this model, it is highly likely that some practices in Somerset would have handed back their GP Contracts (Somerset is the only county in the South West to have no GP Contracts relinquished), and some practices would undoubtedly have closed with the patients dispersed to other practices. This would have impacted the whole health system, with the risk of increased activity in hospitals (increasing costs to the health system), and to other primary care providers who are already under pressure and have limited capacity available to support this additional burden.
9.41 In this context the Trusts note the decision by the Office of Fair Trade (OFT) (the predecessor to the CMA) in “Award of contracts to SSP Health Limited to manage and operate 22 General Medical Practices in Merseyside”107 where the award of the contracts previously held by the Primary Care Trust to SSP was found not to constitute a merger situation given the control exercised by the Commissioner over the practices. Whilst the types of contract may differ, there are considerable levels of control in terms of the need to comply with the NHS primary care regulatory framework which controls the contract in more detail than was the case with the SSP case, and which stipulates detailed non-negotiable requirements for the running of a practice. On this basis there would be no relevant merger situation in relation to the merger of the primary care elements of the services.
9.42 Each practice has a defined practice area under its primary care contract and, in general, in excess of 90 per cent of the patients of a practice will be resident inside the practice area. Most of the practice boundaries of the Trust-owned and independent practices overlap, so patients have a choice of more than one GP practice. Furthermore, we believe that all the patients served by practices run by either YDH (via SHS) or SFT have the option to register with another practice not run by one of the Trusts if they choose. In many rural places in Somerset there is already limited competition as a result of the economics of running a GP practice. These factors may indicate that the extent of any lessening of competition for patients as a result of the proposed merger is minimal.
9.43 Considering these factors overall, the Trusts consider a merger notification is not required as the transaction does not appear to raise the prospect of a substantial lessening of competition and in any event is likely to be exempt by the time the transaction completes. The Trusts will stay in touch with NHSEI as the legislation and the transaction progresses to understand anything which may alter this position.
Stakeholder communications and engagement
9.44 Our ability to deliver the planned benefits of merger depends on each of our clinical and corporate integration projects delivering their specified benefits. This requires close working with colleagues at all levels, and for clinical projects we will need strong
105 YDH employs GP staff through Symphony Healthcare Services, a wholly owned subsidiary established for the delivery of primary care. 106 A combined total of 113,107 registered patients out of a total of 583,921 registered patients.
107 No. ME/5822/12
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clinical engagement. We have already begun engagement with colleagues and stakeholders, see paragraph 5.4.
9.45 Our approach to communications and engagement is informed by learning from the SFT merger. One initiative that worked well in that merger was the creation of a group of Integration Champions – staff drawn from across both Trusts who volunteered to play a role in supporting integration, and who helped develop and convey messages to the wider colleague group. If we receive approval to proceed to Business Case, we will look to establish a similar group for this merger.
9.46 We have already begun to engage with public and patient representatives through the weekly meeting of our Patient Voice Group which includes people with personal, carer and volunteer experience of our acute, community and mental health services and children’s and adult services. With the use of Improvement methodology, this group is helping to shape our developing clinical strategy and inform our thinking around healthcare buildings and technology.
Communications and engagement plan
9.47 We are developing a communications and engagement plan to support the proposed merger of YDH and SFT.
Our communications aims are to: Provide regular communications about the work that SFT and YDH are doing jointly, helping to create an environment of one team working together across Somerset to better meet the needs of our population. Support the proposed merger between our two organisations with communications and appropriate engagement to each stage of the process. Communicate, inform and engage appropriately on the joint work of the two Trusts and our route to potential merger in the context of the development of an ICS in Somerset. Communicate, inform and engage appropriately about what a potential merger means for SFT and YDH.
Our communications objectives are to ensure that: Colleagues at both Trusts, our stakeholders, patients and the public receive regular, open and timely communications about the joint work that SFT and YDH are undertaking that describes: o the reasons for the merger with specific focus on the benefits to patients, carers and communities o what the changes will mean for colleagues, patients and services o developments and our progress to create a new organisation o How the new Trust is building the best from both legacy Trusts, and decisions are made in the interests of continuing excellent patient care. Communications supports the engagement activity that is taking place to support the potential merger of the two Trusts. Colleagues at both Trusts are provided with opportunities and mechanisms to input into the potential merger of the two Trusts and creation of a new organisation and to feedback on our communications.
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Communications principles: Visible, joint leadership through communications and engagement Consistency of narrative and synchronicity of delivery across both Trusts Colleagues at the heart of the new organisation we want to create, receiving information first and having a voice in the creation of the new organisation Patient/service user benefit of change articulated in all communications and engagement activity.
Stakeholders 9.48 The communications and engagement plan will include a comprehensive stakeholder map to ensure that we communicate and engage effectively and consistently with all stakeholders in line with our communications principles in order to achieve our aims and objectives.
9.49 The stakeholder map will include joint stakeholders and those held individually by each Trust and communications messages and engagement will be mapped to each audience, ensuring that we maintain regular communications with them and engage appropriately. This stakeholder map will be jointly held and managed.
Key messages 9.50 Overarching messages will be developed and tailored according to key milestones as the merger programme progresses and will be tailored as appropriate for each stakeholder group. They will set out:
Why our two organisations are potentially merging and both the national and local context for that What the merger will mean for patients and carers What the merger will mean for colleagues What it means for our partners (primary care, Somerset County Council, Somerset CCG, voluntary sector) What kind of organisation we want to create, incorporating what we want to achieve as one organisation and how it will be structured and managed The route to merger and milestones.
Methods and channels of communication 9.51 We will use a range of methods of communication such as: Written briefings Stakeholder letters Written stories/articles Blogs Social media posts Videos News releases and media work Webinars.
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9.52 We will work through both Trusts’ communications channels to reach our internal stakeholders and set up new channels of communication where we identify these are needed (see Figure 56).
Figure 56: Audiences and channels of communication
Audience Channels of communication
Trust-wide colleagues from both SFT Trusts Staff News Blog from chief executive Webinars Intranets YDH CONECTbulletins YCloud intranet CEO video updates, including monthly Board Briefings FAQ Senior colleagues in both Trusts SFT Senior Operational Management Team YDH: Hospital Management Team CONECTmanagers e-bulletins All – provision of support packs for managers to cascade messages and brief teams more personally
Clinicians SFT C2C (consultants only) Senior Operational Management Team Senior clinical team meetings Network via clinical directors YDH Hospital Management Team YDH Clinical Director’s meeting – fortnightly Safety Thermometer – senior nurse meeting Proposed engagement programme including development of clinical strategies across all services.
Councils of Governors SFT Council of Governors meetings Away Days/Development sessions Proposed engagement programme YDH Council of Governors – quarterly Governors’ Breakfasts – quarterly Governors’ e-briefing - weekly Primary care GP Board Engagement via medical director colleagues in both Trusts Text for CCG newsletter and GP bulletin Primary Care Newsletter (produced jointly by YDH and SFT) Proposed engagement programme aligned to development of clinical strategy Local Pharmacy Committee bulletins (via Jill Daniels)
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Somerset Clinical Commissioning Via ICS chief executives Group Via working relationships with CCG colleagues Via CCG’s internal communications channels Other NHS partners/providers Written, phone and face to face contact as needed providing services in Somerset: and in line with communications and engagement programme. South Western Ambulance Trust NHS111 provider (currently Devon Doctors but in procurement) Devon Doctors (GP Out of Hours) Care UK Other NHS partners/providers Written, phone and face to face contact as needed providing services in the South West and in line with communications and engagement programme. Local council partners: Written, phone and face to face contact as needed Somerset County Council and in line with communications and engagement Parish/town Councils programme. District Councils Health and Well Being Board Somerset Overview and Scrutiny Committee Patient representative/ Text supplied for Healthwatch bulletins and website advocacy groups: Text for PPG bulletin Health Watch Issue-based PPI contact PPGs Written, phone and face to face contact as needed and in line with communications and engagement programme. Voluntary/third sector groups: Leagues of Friends Forum Somerset County Council VCSE forum Hospital Leagues of Friends Love Musgrove – through charitable funds committee Love Musgrove Written, phone and face to face contact as needed Other charity organisations and in line with communications and engagement programme. Somerset MPs Written, phone and face to face contact as needed and in line with communications and engagement programme.
Staff representative / advocacy Written, phone and face to face contact as needed and in line groups: with communications and engagement programme.
Staff Side / Trades Unions Media including: Specific briefing when key milestones met Case studies and patient stories demonstrating what the local, regional and national merger will mean for patients, carers and colleagues. broadcast and print media national media health specialists trade press including medical, nursing, scientific and management publications.
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Appendix 1: Supporting submissions
The following documents are available in support of this Strategic Case.
Options appraisal
1. SFT and YDH Board minutes recording discussion of options 2. Deloitte LLP report on options appraisal 25 September 2020 3. Deloitte LLP report on options appraisal 23 October 2020 4. Report to YDH and SFT Boards recommending merger as preferred option
Stakeholder engagement
5. ICS letters of support
Due diligence
6. Summary findings of initial legal Due Diligence – report to YDH Board 7. Summary findings of initial legal Due Diligence – report to SFT Board 8. Summary findings of initial non-legal Due Diligence – report to YDH Board 9. Summary findings of initial non-legal Due Diligence – report to SFT Board
Project management
10. Transaction programme plan (detailed) 11. Benefits realisation methodology slide pack
Governance
12. Memorandum of Understanding, May 2020 13. Provider Development Committee Terms of Reference 14. Integration risk register 15. YDH corporate risk register 16. SFT corporate risk register
Quality
17. CQC inspection report on TSFT, published March 2020 18. CQC inspection report on SPFT, published January 2019 19. SFT CQC action plan 20. CQC inspection report on YDH, published May 2019 21. YDH CQC action plan
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Appendix 2: Somerset health and care key challenges
Demography – an ageing population
1. ONS data suggest the current population of Somerset is around 562,000.108 ONS also estimates that 24.9 per cent of Somerset residents (c.140,000 people) are aged 65 or over. This is significantly higher than the average for England of 18 per cent.
2. By 2043, the ONS predicts that the Somerset population will rise by around 13 per cent to 635,000. At this point, the percentage of over 65s in Somerset is predicted to account for 33 per cent of the total population, against a national average of 24 per cent,109 and the number of people over 75 in Somerset will have nearly doubled to 121,000. In parts of West Somerset and Burnham-on-Sea, more than half the population is expected to be aged 65 or over by 2033110. Figure 57 shows Somerset population projections by age.
Figure 57: Population projections by age, Somerset 2016-2041111
3. Figure 58 below shows ONS population estimates for 2018 illustrating that Somerset’s proportion of older age residents is higher than the England and South West averages. It also demonstrates the relative under-representation in the county of people aged 20 to 44.
108 Office for National Statistics 2019 mid-year population estimates, April 2020. 109 Office for National Statistics 2018-based population projections, March 2020. 110 http://www.somersetintelligence.org.uk/older-people/ 111 http://www.somersetintelligence.org.uk
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Figure 58: Somerset age profile
4. Across England, 15 per cent of those aged 65 or over are moderately or severely frail. Older people make greater use of health care services than people of working age. This means the demands on the Somerset health and care system are proportionately greater than in a comparable region with the same total population but a more balanced demography. Because Somerset has a below average proportion of working age residents compared to England as a whole, this is likely to reduce the number of adults able to provide unpaid care for a close friend or relative.
Complex needs
5. People with one or more long-term conditions now make up 30 per cent of the population of England, account for 50 per cent of all GP appointments, 64 per cent of all outpatient appointments, and occupy 70 per cent of hospital beds.
6. By 2035, two-thirds of adults in England are expected to be living with multiple health conditions, and 17 per cent will have four or more conditions.112 In Somerset 4 per cent of patients account for 50 per cent of all health expenditure.
112 https://www.england.nhs.uk/wp-content/uploads/2019/01/universal-personalised-care.pdf
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Inequalities
7. At the 2011 census, 19 per cent of the Somerset population said they had a long-term condition or disability.113 Data from the Symphony programme indicates that around 4 per cent of people in Somerset have two or more long-term conditions.114
8. The number of children in England with profound and multiple learning difficulties has increased by 40 per cent since 2004. More than 15 per cent of young people in Somerset have special educational needs or a disability.115
9. Somerset is in the worse quartile nationally for rate of suicide.116 The hospital admission rates for people who have self-harmed or have misused alcohol are higher than benchmark,117 which either indicates greater rates of mental distress in the county or that we are missing opportunities to intervene sooner with these groups.
10. 66 per cent of adult Somerset residents are overweight or obese compared to an England average of 65 per cent.118 Latest data (from 2016) indicate 12 per cent of the adult population of Somerset are smokers.119
11. The life expectancy of women in Somerset with a mental health disorder is 17.5 years lower than for women without serious mental illness; for men in Somerset the difference is 19.7 years. 120 This discrepancy is replicated around the country and is attributed mainly to cardiovascular disease and cancer, rather than the underlying mental health condition.
12. In England, people affected by homelessness die on average around 30 years younger than the general population; drug or alcohol misuse, cardiovascular disease and suicide are the leading causes of death.121 In 2017/18, c. 400 households in Somerset were declared statutorily homeless and there were c.60 rough sleepers122. Anecdotally, homelessness has increased during the pandemic. People affected by homelessness often have complex health needs and are much more likely than the general population to experience depression, substance misuse and require emergency hospital admission.
Socio-economic position 13. Although Somerset has lower overall deprivation than the England average, pockets of deprivation exist which create and exacerbate ill health, and deprivation is worsening.
113 2011 Census profile for Somerset, via www.somersetintelligence.org.uk 114 http://www.somersetintelligence.org.uk/files/JSNA%202017%20Ageing%20Well%20Summary.pdf 115 Hidden Somerset, Somerset Community Foundation https://www.yumpu.com/en/document/read/63829959/hidden-somerset- unseen-youth 116 https://fingertips.phe.org.uk/profile/health-profiles/data#page/1/gid/1938132696/pat/6/par/E12000009/ati/102/are/E10000027/iid/41001/age/285/sex/4/cid/4/page-options/ine-vo-0_ine-yo-1:2015:-1:-1_ine-ct- 39_car-do-0_car-ao-0 117 Public Health England fingertips data https://fingertips.phe.org.uk/profile/public-health-outcomes- framework/data#page/1/gid/1000042/pat/6/par/E12000009/ati/102/are/E10000027/cid/4 118http://www.somersetintelligence.org.uk/obesity.html#:~:text=The%20Somerset%20District%20with%20the,or%20obese%20(NCMP%2 02016). 119http://www.somersetintelligence.org.uk/smoking.html#:~:text=12.3%25%20of%20the%20adult%20population,of%20them%20in%20mi ddle%20age. 120 Making the Case for Integrating Mental Health and Physical Healthcare, Midlands and Lancashire Commissioning Support Unit, May 2017. 121 https://www.crisis.org.uk/media/236798/crisis_homelessness_kills2012.pdf 122 http://www.somersetintelligence.org.uk/homelessness.html
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The number of neighbourhoods classed as ‘highly deprived’ rose from 25 to 29 in the period 2015-19, and around 47,000 people now live in such neighbourhoods.123 The most deprived area of Somerset is the Highbridge South West area of Sedgemoor.124
14. The male healthy life expectancy at birth for those living in the most deprived parts of Somerset is 8.9 years lower than for those living in the most affluent areas. The difference for females is 8.0 years.125
15. Many long-term conditions are more than twice as common in adults from lower socio- economic groups, and mental health problems are also more prevalent126. Around 1 in 10 households in Somerset is in fuel poverty, often living in damp, cold conditions which cause and exacerbate health problems.127
16. 13 per cent of children in Somerset are growing up in a low-income household,128 and childhood poverty is linked to premature mortality and poor health outcomes in adulthood.
17. Food bank use in the South West rose 63 per cent between 2013/14 and 2019/20129 and there are clear links between foodbank use and poor health. In 2018/19 26,000 emergency food parcels (containing food for three days) were issued to people in Somerset.130 Research in 2018 found that 19 per cent of people using foodbanks have a disability, 23 per cent have a long term health condition, and 38 per cent suffer from mental ill health.131 The situation has worsened significantly as a result of Covid-19. According to The Trussell Trust, 50 per cent of people using food banks at the start of the pandemic had not needed one before.
Geography 18. Somerset is geographically large and one of the most rural counties in England with a population density of 1.5 people per hectare (compared to a national average of 4.1).132 48 per cent of people in Somerset live in a rural area.133 People with the worst health and the lowest incomes struggle the most to travel to health services134. One in five Somerset residents aged 65 or over has no access to car or van; the proportion is even higher in amongst women,135 and public transport links in the county are poor. This creates challenges for access to our services. Furthermore, rurality contributes to social isolation and is linked to digital poverty.
123 http://www.somersetintelligence.org.uk/files/English%20Indices%20of%20Deprivation%202019%20-%20Somerset%20summary.pdf 124 English Indices of Deprivation 2019 www.somersetintelligence.org.uk 125 https://fingertips.phe.org.uk/profile/public-health-outcomes- framework/data#page/1/gid/1000049/pat/6/par/E12000009/ati/102/are/E10000027/cid/4/tbm/1 126 https://www.bma.org.uk/media/2084/health-at-a-price-2017.pdf 127 https://www.gov.uk/government/statistics/sub-regional-fuel-poverty-data-2020 128 http://www.somersetintelligence.org.uk/cyp/ 14,300 children of 110,000. 129 https://www.trusselltrust.org/news-and-blog/latest-stats/end-year-stats/ 130 https://www.somersetlive.co.uk/news/somerset-news/record-numbers-children-adults-somerset-3431041 131 The Trussell Trust: Disability, Health and Hunger, 2018 132 https://www.yumpu.com/en/document/read/63829671/hidden-somerset-rural-isolation 133 http://www.somersetintelligence.org.uk/profile-of-rural-somerset-from-the-2011-census.html 134 English Longitudinal Study of Ageing 2012/13 135 2011 Census
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Rising demand – Acute care
19. According to forecasts by Archus based on ONS population forecasts, A&E admissions at SFT are expected to rise by 17.1 per cent (cumulative growth) by 2034. Similar forecasting work is currently underway for YDH but is expected to show a similar increase as it will be based on the same population forecasts.
20. Independent forecasting by consultants Factor 50 suggests aggregate projected growth in elective demand through to 2024 will be 1.6 per cent per year. Forecasts by service are below (Figure 59).
Figure 59: Demand growth forecasts by RTT treatment function
Clock starts year 2019-24 percentage expected RTT treatment function to end 2020 growth in Somerset per year Trauma & Orthopaedics 26,443 1.0 General surgery 24,697 2.5 Ophthalmology 20,234 1.4 Other 24,278 0.9 ENT 14,186 0.9 Gynaecology 12,640 3.5 Dermatology 9,838 3.6 Urology 9,717 1.5 Gastroenterology 9,257 0.9 Cardiology 9,049 1.6 Thoracic Medicine 4,958 1.4 Neurology 3,794 0.6 Rheumatology 3,521 1.6 Geriatric Medicine 2,225 2.2 General Medicine 1,565 1.1 Plastic surgery 1,346 0.9 Neurosurgery 385 1.1 Cardiothoracic surgery 206 1.1
Uncertain demand – Community services
21. Our best estimate of external referrals for community physical health services is set out below. The pandemic makes it extremely difficult to forecast referral levels, in part because the level of demand in 2020/21 was so unusual compared to previous years. The projections below are based on demographic growth forecasts, recent changes observed in demand, and service directors’ views about the likely future impact of Covid on their respective services, see Figure 60. While we expect total referrals in 2020-21 to fall as a result of the pandemic, demand is expected to rise again in 2021- 22.
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Figure 60: Demand growth projections for community physical health services
External referrals 2018-19 2019-20 2020-21 2021-22 projected projected Community 138,967 137,511 113,504 132,016 physical health (-1% year on (-17% year on (16% year on services year) year) year)
Rising demand – mental health community services
22. Research commissioned by NHSEI136 estimates that as a result of the pandemic, demand nationally for adult mental health services could rise by up to 40 per cent. It also estimates that demand for CAMHS could rise by up to 60 per cent, and by up to 20 per cent for older people’s mental health services. The research concluded that the development of mental health conditions as a result of the pandemic is likely to occur over a long period of time.
23. Our best estimate of external referrals for community mental health services in Somerset is set out below. The pandemic makes it extremely difficult to forecast referral levels, in part because the level of demand in 2020/21 was so unusual compared to previous years. The projections below are based on demographic growth forecasts, recent changes observed in demand, and service directors’ views about the likely future impact of Covid on their services, see Figure 61. The 2021-22 demand projection represents a 20 per cent increase on pre-covid levels of demand for mental health services.
Figure 61: Demand growth projections for community mental health services
External referrals 2018-19 2019-20 2020-21 2021-22 projected projected Community 45,837 51,470 60,132 61,764 mental health (12% year on (17% year on (3% year on services year) year) year)
Historic underinvestment in community mental health services
24. Data from the NHS Benchmarking Network’s 2019 Mental Health benchmarking project shows that Somerset’s number of adult inpatient mental health beds is around the national average. However, funding for our adult community mental health services is in the lowest quartile nationally according to the 2019 benchmarking data (see Figure 62).
136 https://www.hsj.co.uk/mental-health/mental-health-demand-could-rise-by-40pc-warns-nhse-research/7029085.article
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Figure 62: Comparative spend on community mental health services
All CMHTs - Total pay Community Mental Health Teams 2018/19 per 100,000 weighted population £6,000,000
£5,000,000
£4,000,000
£3,000,000
£2,000,000
£1,000,000
£0
MH32
MH39
MH93
MH28
MH61
MH65
MH06
MH15
MH53
MH66
MH92
MH41
MH63
MH12
MH08
MH95
MH57
MH35
MH21
MH74
MH27
MH09
MH17
MH05
MH23
MH42
MH44
MH18
MH56
MH40
MH20
MH29
MH45
MH94
MH11
MH24
MH36
MH50
MH10
MH07
MH37
MH03
MH22
MH16
MH19
MH04
MH33
MH34
MH25
MH52
MH60
MH38
MH02
MH26 MH54
All Organisations Q39 MH19 Mean Lower Quartile Median Upper Quartile
N.B. Somerset FT is shown in red MH19.
25. Despite recent investment in mental services, NHS Mental Health benchmarking data for 2019-20 shows that for 9 of the 14 services benchmarked the spend in Somerset per weighted 100,000 population is still below national average (see Figure 63). Spend in 5 of those services is in the bottom quartile.
Figure 63: Comparative spend on mental health services
Indicator SFT spend National Comment in 2019/20 average
Assertive Outreach – Total costs of service per 100,000 weighted £204,316 £308,104 Fourth population Quartile
Early Intervention (including Early Onset Psychosis) – Total costs of £181,944 £411,194 Fourth service per 100,000 weighted population Quartile
Older Adult Inpatient – Total costs of service per 100,000 weighted £1,540,127 £4,110,582 Fourth population Quartile
PICU Inpatient – Total costs of service per 10 beds £1,735,195 £2,901,374 Fourth Quartile
Older People – Total costs of service per 100,000 weighted £1,908,516 £3,122,416 Fourth population Quartile
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Adult Acute Inpatient – Total costs of service per 100,000 weighted £2,568,267 £2,652,543 Third population quartile
Low Secure Inpatient – Total costs of service per 10 beds £1,536,869 £1,677,810 Third quartile
All CMHTs – Total costs of service per 100,000 weighted population £4,666,702 £5,084,889 Third quartile
Eating Disorders – Total costs of service per 100,000 weighted £114,291 £151,520 Third population quartile
CRHT – Total costs of service per 100,000 weighted population £1,410,590 £1,288,110 Second quartile
Forensic – Total costs of service per 100,000 weighted population £309,553 £276,537 Second quartile
Perinatal – Total costs of service per 100,000 weighted population £216,234 £191,285 Second quartile
High Dependency Rehabilitation Inpatient – Total costs of service £1,791,906 £1,333,442 Upper per 10 beds Quartile
Generic CMHT – Total costs of service per 100,000 weighted £4,020,936 £2,849,550 Upper population Quartile
N.B. all service costs including corporate costs and overheads.
26. The lack of investment in mental health creates pressure on other parts of the system. For example, the number of admissions to adult mental health inpatient beds per weighted head of population is amongst the highest in the country (5th highest of 56 mental health trusts benchmarked) and we have comparatively higher levels of emergency readmissions within 30 days of discharge from an inpatient mental health bed. At their last inspection of YDH the CQC expressed concern about the admission of children with mental health problems where there were no beds available for them in specialist mental health services. This underinvestment is particularly worrying given the expected rise in mental health need as a result of Covid-19.
Resources focused on bed-based care
27. A report in October 2018 by NHSEI into the drivers of the deficit in the Somerset system137 concluded there was evidence that some of system deficit was linked to the bed-based model of community services rather than a more integrated and responsive community-based model. A clinical utilisation review in 2018 supported this and showed that, at the time of the review, 2 in 3 people in inpatient beds in Somerset could have been cared for in a less intensive setting if alternative services with capacity had been available.138
28. Benchmarking analysis done in 2016 of the number of community hospital beds per 100,000 population in South West counties and other Clinical Commissioning Group areas nationally with characteristics similar to Somerset found an average of 34
137 Drivers of the Deficit for the Somerset NHS System, October 2018. 138 Care Utilisation Review, Aptean, 5/9/18.
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community beds per 100,000. More recent benchmarking data on the number of community hospital beds is not available, but we do know that since 2016 the number of acute beds has fallen nationally, as has the number of mental health and learning disabilities beds. With the introduction of new care models, it is reasonable to believe that the average number of community beds nationally has fallen too.
29. The number of community beds in Somerset is currently 190 (down from 222 a few years ago), which equates to around 34 community beds per 100,000 population. This would suggest the number of community beds in Somerset is at best now around benchmark but more likely above benchmark if we are correct in our assumption that the number of community beds elsewhere has fallen.
30. A recent set of clinical reviews139 performed in January-February 2021 found that 91 of 136 patients in Somerset’s community hospitals did not require bedded care and would have been better cared for in other settings such as nursing care. Therefore, we know that there are still many people in bedded care who do not need to be there, and there is scope to further reduce our reliance on bed-based care.
Covid-19
31. Like the rest of the NHS, the emergence of Covid-19 has placed the Somerset health and care system under extraordinary and unprecedented pressure. New infection prevention measures and staff sickness absence have made it difficult to care for people both with and without the virus. Under mutual aid arrangements, SFT has treated some Covid patients transferred from Weston General Hospital which has added to this pressure. Somerset’s elective waiting lists have increased during the pandemic and we know there is pent-up demand from people too fearful to attend an appointment in a healthcare setting or who do not want to trouble the NHS while the pandemic continues. Although the advent of the virus has prompted new ways of working, it will take us years to recover from the operational and financial consequences, and Covid-related issues will continue to draw management time from business as usual for some time to come.
Workforce recruitment
32. Somerset faces challenges around the recruitment of nursing and medical staff across a wide range of roles and specialties. The fact that Somerset has a below average proportion of residents of working age compared to England as a whole exacerbates the recruitment challenges in the county. Workforce gaps make it harder to deliver services that meet constitutional standards.
33. As at December 2020, SFT had 216 whole time equivalent unfilled registered nurse posts which represents a vacancy rate of 9 per cent. As at December 2020, YDH had 4 whole time equivalent unfilled nursing posts (1 per cent vacancy rate).
34. Both Trusts also have medical workforce recruitment challenges. At December 2020, SFT had 43 whole time equivalent consultant vacancies, representing a 12.5 per cent consultant vacancy rate (in specialties including Cardiology and Care of the Elderly),
139 Practice development forums.
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plus 31 other medical vacancies. YDH had 4 consultant vacancies at the same point, although this figure has only recently reduced.
35. To maintain safe services, SFT spent £9.7 million140 in the 9 months to December 2020 on temporary clinical staff. YDH spent £6.7 million in the same period on temporary clinical staff 141 in part due to colleagues shielding, self-isolating or off sick as a result of covid-19.
Financial pressures
36. Both Trusts have underlying financial deficits driven in part by diseconomies of scale due to size and rurality. After PSF and FRF142, SFT and YDH are forecasting to end the year at breakeven. However, these positions include exceptional Covid funding arrangements and so do not reflect the true underlying financial positions.
37. In 2019/20 the combined Somerset system deficit was £9.7 million. However, this includes £44.0 million of PSF, FRF and CSF143. Providers’ achievement of CIP targets is becoming increasingly difficult to deliver year on year, and neither of the Trusts nor the CCG in Somerset is likely to be financially sustainable in the coming years without transformational change to the way health services are delivered.
140 Between April-December 2020, SFT spent £8.5 million on agency staff and £1.219 million on locum staff. 141 Between April-December 2020, YDH spent £5.248 million on agency staff and £8.365 million on locum staff. 142 Provider Sustainability Funding; Financial Recovery Funding. 143 Commissioner Support Funding.
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Appendix 3: Quality ratings and well-led reviews
Somerset NHS Foundation Trust CQC report
1. Somerset NHS Foundation Trust (SFT) was formed on 1 April 2020 through a merger by acquisition of Somerset Partnership NHS Foundation Trust (SPFT) and Taunton and Somerset NHS Foundation Trust (TSFT).
2. The most recent Care Quality Commission (CQC) reports relate to these predecessor organisations, although it should be noted that a joint executive team was in place at the time of both inspections which was particularly pertinent for the review of the well- led domains. The CQC inspected SPFT in October 2018 and TSFT in January 2020.
3. TSFT was rated ‘good’ overall, ‘outstanding’ for caring, ‘good’ for the effective, well- led, responsive and productive use of resources domains and ‘requires improvement’ for the safe domain, see Figure 64.
4. SPFT was rated ‘good’ overall, ‘good’ for the effective, caring, responsive and well-led domains and ‘requires improvement’ for the safe domain, see Figure 65.
5. The full CQC reports are provided as a supporting submission to this Strategic Case.
Figure 64: CQC inspection ratings of TSFT, January 2020
Figure 65: CQC inspection ratings of SPFT, October 2018
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6. It is positive that in forming SFT both Trusts were rated as ‘good’. Both inspections highlighted further areas for improvement and good progress has been made in delivering against the ‘must do’ and ‘should do’ actions. There remain a small number of residual actions, a summary of which is set out below, see Figure 66 and 67.
Figure 66: CQC ‘must do’ actions for TSFT
MUST 1 Learning from death arrangements (Trust-wide) Ensure the mortality investigations, encompassing the National Quality Board learning from death requirements, are strengthened to be consistent, structured, and of a good quality, meet Trust policy, are reported on at the Trust Board, and show there is learning from death. Families or those who cared for the patient must be involved where they want to be in any investigations into the death where there were failings in care.
Response: With the recruitment in 2020 of a Learning from Deaths Lead and with senior medical leadership, there has been a significant focus on process developments. These include full adoption of structured judgement review methodology and strengthening the infrastructure for identifying learning and for family involvement. The success of these developments was recognised at a review meeting with the CQC held in February 2021.
MUST 2 Anaesthetic cover for critical care and maternity (Trust-wide) Ensure there are safe levels of anaesthetists on duty and available at all times that meets the guidelines for provision, specifically for maternity services and critical care and when operating out of hours. The lack of full 24-hour cover from anaesthetists meant not all women were receiving timely epidurals in maternity. In critical care there was a risk of a patient being delayed if an advanced airway practitioner was not available due to full cover not being provided. We acknowledge this was on the Trust’s corporate risk register.
Response: In the context of Covid-19, the rota for anaesthetic 24-hour cover has been put in place including senior cover for weekend shifts. Epidural attendance has reliably met the 30-minute standard. Review of data for advanced airway attendance (by anaesthetists in ED) has been improved via the establishment of a Trauma Committee.
MUST 3 Assurance of safety equipment checks (Trust-wide) Ensure all safety equipment in all areas of the Trust is checked as required in line with Trust policy and national safety standards. Ensure there are governance processes to determine accurately and with full assurance that this is addressed as this was a failure on our previous inspection. This was specifically an issue with maternity services, critical care and the acute medical unit.
Response: System development continues with the design and implementation of a digital solution for assurance of equipment checks, the focus being on resuscitation trolley equipment. Following a pilot phase, the focus is on refining the processes for recording checks, to ensure the required accuracy of reported performance.
MUST 4 Restricted access for critical care unit (critical care) Ensure public access to the critical care unit is always restricted by locking the unit and consider the installation of an intercom system and CCTV.
Response: Controlled access was addressed immediately with the installation of swipe access for the unit.
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Figure 67: CQC ‘must do’ actions for SPFT
There were four ‘must do’ actions arising from the SPFT inspection in 2018, all related to specialist community mental health services for children and young people (CAMHS). All ‘must do’ actions arising from the SPFT inspection have been completed.
MUST 1 Risk assessments - review and supporting information The provider must ensure that risk assessments are updated regularly and ensure that when risks are identified there is clear information available.
Response: Revised audit and monitoring arrangements, review of the electronic record for risk assessment and care planning, and training were delivered. The focus was on embedding risk assessment into the processes for care planning.
MUST 2 Waiting list - CAMHS The provider must act to mitigate the risk to the number of young people on the waiting list for assessment in the east CAMHS team.
Response: Improvements to waiting list performance was achieved through a range of mechanisms including enhanced senior management team review of waiting list reports and the introduction of assessment clinics. Training in therapeutic skills and recruitment to team vacancies also contributed to the response.
MUST 3 Complaints management The provider must ensure that all complaints received are logged, investigated, responded to and acted upon.
Response: Revised and strengthened reporting and oversight arrangements were put in place.
MUST 4 Systems and process for clinical records The provider must have effective systems and processes in place to assess, monitor and improve clinical records.
Response: Improvements focused on case management system development, training in Care Programme Approach and introduction of routine outcome measurement.
7. There are three of 23 outstanding ‘should do’ actions from the inspection of SPFT that remain open and continue to be monitored. 56 ‘should do’ actions were identified by the CQC following the inspection of TSFT, the majority of which have now been delivered or are on track. An assurance process is in place to establish the live status and to confirm when there is evidence to support full completion of the actions. Oversight is via SFT’s Quality and Governance Committee.
8. The action plans developed in response to the inspections were amalgamated when SFT was formed. This action plan is provided as a supporting submission to this Strategic Case. The first section addresses residual open actions from the SPFT inspection and then the ‘must do’ and ‘should do’ actions from the TSFT inspection.
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SFT quality priorities
9. A new clinical model was developed when SFT was created which had four long-term aims. These are: Aim 1: Provide safe, effective, high quality, person-centred care in the most appropriate setting. Aim 2: Deliver care closer to home in neighbourhood areas with an emphasis on self-management and prevention. Aim 3: Give equal priority to physical and mental health, and value all people alike. Aim 4: Improve outcomes for people with complex conditions through personalised, co-ordinated care.
These aims have since been developed, together with system partners into the 5 clinical aims set out in Chapter 5.
10. SFT’s five quality priorities for 2020/21 matched the clinical model’s year one ‘flagship’ programmes. The flagship programmes are areas that are seen as key areas of focus for year one to support the overall delivery of the clinical aims.
Priority 1: Independent lives - helping older people to live as they wish, giving them time to do what is important to them. Priority 2: Stolen years - helping people with mental health conditions to live longer lives. Priority 3: Last 1,000 days - valuing people’s precious time in the last chapter of life. Priority 4: Connecting us - using time well by getting together to focus on what matters to people with complex needs. Priority 5: Function first - improving life chances for children by increasing their time in school.
11. Delivery of the flagship programmes and quality priorities has been by the Covid-19 pandemic. For instance, in some cases implementation has been accelerated (frailty flagship), reframed (stolen years) or reassessed/paused (increasing children’s time in school). Progress is monitored via an action plan specifying the executive and senior manager leads for each priority. In addition, on a monthly basis, quantitative updates against key quality measures are reported within the quality and performance report to the Trust Board.
SFT well-led review
12. In November 2017, Deloitte LLP completed independent leadership and governance reviews of SPFT and TSFT under the well-led framework. A number of areas of good practice were identified, but in both instances the Trusts partially met the requirements. Following the review, the Trusts developed action plans to address those areas where further progress was needed and subsequently delivered against all actions to meet the requirements fully.
13. It is not intended at this stage to undertake another external well-led review, but SFT regularly undertakes internal reviews of its governance arrangements; an internal review of Board effectiveness is planned for April 2021.
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Yeovil District Hospital NHS Foundation Trust CQC report
14. The CQC inspected Yeovil District Hospital NHS Foundation Trust (YDH) in December 2018/January 2019 and produced two ratings, one for the Yeovil Hospital site and one for the Foundation Trust overall.
15. Yeovil Hospital was rated as ‘good’ overall and ‘good’ for the effective, caring, responsive and well-led domains and “requires improvement” for the safe domain, see Figure 68.
Figure 68: CQC inspection ratings of Yeovil Hospital, 2018/19
16. Overall, Yeovil District Hospital NHS Foundation Trust was rated ‘requires improvement’, ‘good’ for the caring, effective and responsive domains, ‘requires improvement’ for the safe and well-led domains and ‘inadequate’ for the productive use of resources domain, see Figure 69.
Figure 69: CQC inspection ratings of Yeovil District Hospital NHS Foundation Trust 2018/19
17. The full report is provided as a supporting submission to this Strategic Case.
18. While the overall rating for the Foundation Trust remains unchanged compared to its previous rating, CQC inspectors identified clear progress in a number of areas. The combination of the financial use of resources report which was based on an
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assessment undertaken by NHSEI (rated ‘inadequate’), and the CQC’s inspection for the quality of services, has resulted in an overall rating of ‘requires improvement’ for the Foundation Trust. Nonetheless the quality of services was rated as ‘good’ across three domains and ‘good’ overall for the Yeovil Hospital site.
19. CQCs ‘must do’ actions are set out in Figure 70.
Figure 70: CQC ‘must do’ actions for YDH
The ‘must do’ actions’ arising from the YDH inspection related to:
MUST 1
Ward 10 (children and young people) environment
Ensuring the environment of ward 10 is suitable and safe for all children and young people who are admitted for care and treatment, and preventing children and young people from having access to areas of the ward which are potentially harmful to them.
Response: An estates review is underway aligned with Somerset’s overarching Fit for My Future strategic objectives to review children’s services, including Child and Adolescent Mental Health Services, at system level. All other deliverables against this ‘must do’ have been achieved.
MUST 2
Completing and escalating early warning scores appropriately
Response: All deliverables against this ‘must do’ action have been completed.
20. 62 ‘should do’ actions were identified by the CQC following the inspection of YDH, with only 6 left to complete.
21. Good progress has been made in delivering against the ‘must do’ and ‘should do’ actions, many of which have been delivered or are on track, although it should be noted that the action plans have not been updated since May 2020 because of the need to respond to the Covid-19 pandemic. The action plans are provided as supporting submissions to this Strategic Case.
YDH quality priorities
22. YDH had intended to base its 2020/21 quality priorities on the 2020/21 CQUIN programme, as set out in Figure 71. However, work on these areas has been impacted by Covid-19. Quality and patient safety priorities for 2020/21 have therefore focused on preparing and managing the Covid-19 response to date. The Trust expects to present priorities relating to the Covid-19 pandemic response in next year’s Quality Report.
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Figure 71: 2020/21 CQUIN programme
YDH well-led review
23. YDH took part in a joint CQC/NHSEI pilot inspection under the newly introduced well- led framework in 2017/18. This pilot inspection was considered to fulfil the requirements outlined in the well-led framework. A number of areas of good practice were identified alongside a range of actions for improvement which have now been delivered and/or superseded by the CQC/NHSEI use of resources report from 2018/19.
24. It is not intended at this stage to undertake another external well-led review, but YDH regularly undertakes internal reviews of its governance arrangements. In 2019/20, the Trust’s internal auditors were asked to complete a governance effectiveness review. A number of areas of good practice were identified from the review, alongside potential opportunities, including reviewing/reducing the membership of the Board committees.
25. Prior to 2019/20, YDH undertook a review of the effectiveness of the Board of Directors. This review included a revised schedule for the Board that now rotates between strategically and operationally focussed meetings.
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Appendix 4: Operational performance detail
1. The Covid-19 outbreak continues to have a significant impact on a range of constitutional access standards, with the number of patients waiting for treatment increasing, and waiting times lengthening. Urgent and emergency patients continue to be prioritised for the care they need.
2. Performance across a broad range of indicators is anticipated to continue to be adversely affected over the coming months as our Trusts continue to manage their responses to and recover from Covid-19.
SFT operational performance
3. This section summarises operational performance at SFT against key constitutional standards and actions to address underperformance.
Emergency department (ED) and minor injury unit (MIU)
4. ED attendances (January 2021) were 33 per cent below trajectory which is thought to be due to the continuing impact of Covid-19. Similarly, emergency admissions are 17 per cent down on January 2020 levels.
5. Latest ED four-hour performance was 73.9 per cent for the Musgrove Park Hospital site (January 2021). This reflects increasing pressure on bed availability due to a sharp rise in Covid-19 related admissions.
6. Performance against the ED four-hour standard, and other key performance indicators of urgent care management, has generally been maintained at a higher level since Covid-19 began.
7. Latest performance against the MIU four-hour standard was 99.5 per cent in January 2021, and performance has been above 99 per cent every month for the year to date.
8. The national average performance for trusts with a major ED was 70.1 per cent in January 2021. SFT’s performance was 73.9 per cent which ranked 63 out of 113 trusts. With MIU attendances included, this ranking improved to 24, with performance of 91.6 per cent.
9. Latest performance against the 15-minute triage time for patients arriving by ambulance was 88.5 per cent (January 2021), which continues to be below the 95 per cent standard. Performance against this standard varies with the level of ambulance arrivals and the impacting pressure on the department.
10. The number of 12-hour trolley waits has been maintained at zero all year.
11. The focus of ongoing improvement work includes:
The heralded arrivals pathways (i.e. pre-warning that a patient is being sent: 111 First was launched in November 2020 to support awareness of urgent activity flow into the department). The ED is revising the bed requesting and allocation process to reduce delays with admitting patients from ED.
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The ED improvement plan contains further actions to support quality and safety within the department.
Access to community services
12. In January 2021, the number of patients waiting 18 weeks or more was 2,214, with 2,172 patients waiting 18 weeks or more to be seen by the Somerset and Dorset dental service, and 33 patients waiting 18 weeks or more to be seen by the OASIS (orthopaedic interface) service.
13. The significant increase in numbers waiting, especially within dental services remains principally due to the measures being undertaken in response to Covid-19.
14. Across all community services, 97.2 per cent (January 2021) of patients were waiting less than 18 weeks for treatment, which is better than the threshold of 92 per cent.
15. In accordance with nationally mandated guidance relating to the management of Covid-19, priority continues to be given to urgent and emergency patients. Services are continuing to contact non-urgent patients via telephone and video to provide advice and support. The expectation is that waiting times performance will continue to deteriorate until usual arrangements have been restored.
Cancer standards
16. The percentage of patients seen within 14 days of referral by their GP with a suspected cancer was 89.9 per cent in December 2020, which was above the national average of 87.5 per cent for that month. Performance above the national standard of 93 per cent was achieved twice in year.
17. The focus of ongoing improvement work includes:
Delays in receiving blood test results for patients referred with a suspected upper GI cancer has been addressed from January 2021, with bloods being taken in clinic if results are not available from GPs by the time of the appointment. Telephone consultations are taking place where patients do not need to be seen face-to-face. Where patients need to attend an appointment or diagnostic test in person, precautions are taken by physically spacing-out patients in waiting areas and limiting the number of clinics run at any one time. Plans are in place to increase CT colon and endoscopy capacity, and for a pilot of one-stop prostate cancer clinics from April 2021 in line with nationally recommended pathways.
18. The percentage of patients with cancer treated within 62 days of referral by their GP was 77.4 per cent in December 2020, which was above the national average of 75.2 per cent. Patients treated for colorectal cancers made up 34 per cent of breaches of the standard, reflecting the reduced capacity for endoscopy and CT colon tests during and following the Covid-19 peak. The national standard of 85 per cent has not been met all year.
19. The focus of ongoing improvement work includes:
Patients continue to be prioritised for cancer treatment in line with the national prioritisation codes and timescales.
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Rapid diagnostic service (RDS) principles are being applied to key cancer pathways to reduce the length of the diagnostic phase. A pan-Somerset RDS referral hub is being established from June 2021 for patients with non-specific symptoms of cancer, but with signs of significant illness. Patients referred with a suspected prostate cancer are now being triaged straight to test (MRI scan); a one-stop outpatient and MRI scan is planned to start in early April 2021. Radiology will be using artificial intelligence (AI) reporting software to speed up the diagnostic pathway for lung cancer patients from April 2021.
Acute referral to treatment (RTT) waiting times
20. All aspects of acute RTT performance continue to be heavily impacted by the Covid-19 outbreak due to capacity being re-purposed, capacity lost due to additional infection control measures, a shortfall of staff, social distancing and patient choice not to attend.
21. Day surgery, inpatient theatres, diagnostic and outpatient capacity was restored to near pre-Covid levels in November and December 2020. However, capacity had to be repurposed again during the second wave of Covid-19. This included a reduction in operating theatres to support an expansion of critical care beds and staffing, and one of the Trust’s outpatient departments being used (until the end of March 2021) for the hospital Covid-19 vaccination hub. With the loss of capacity, routine backlogs and waiting lists are forecast to rise during quarter four 2020/21.
22. In January 2021, the percentage of patients waiting under 18 weeks RTT was 59.4 per cent. The national average was 67.8 per cent (December 2020).
23. There were 2,501 people waiting more than 52 weeks for treatment in January 2021. The target is that no one should wait more than 52 weeks.
24. The total waiting list size as at January 2021 was 22,916.
25. The focus of ongoing improvement work includes:
The emphasis during the Covid-19 outbreak is to keep patients safe, with those with urgent conditions continuing to be prioritised. There is an active programme of system-wide actions to support long-term recovery and efficient use of available capacity, including aspirational plans to re-configure referral pathways so that capacity is evened out across the county (single points of access project) and/or patients being referred automatically for secondary care advice and guidance as a first step (advice first project). A modular eye theatre is being added to the Musgrove site in the summer of 2021 (25 per cent of the patients waiting over 52 weeks are ophthalmology patients).
Diagnostic six-week wait
26. All aspects of diagnostic performance continue to be impacted by the Covid-19 outbreak, and this has meant that only 61.0 per cent of patients had their diagnostic test within six weeks (January 2021). The national standard of 99 per cent has not been met all year.
27. The number of patients waiting over six weeks was 2,464 in January 2021.
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28. The total size of the waiting list was 6,322 in January 2021.
29. The focus of ongoing improvement work includes:
Capacity has been increased, but social distancing, personal and protective equipment and cleaning measures put in place to manage patient care during the Covid-19 outbreak continue to impact on throughput. Two additional MRI vans have been in situ since October 2020, to replace capacity lost through the upgrade of an on-site scanner. This upgrade was completed at the end of February 2021. Ventilation works were completed at Bridgwater Community Hospital in November 2020, allowing endoscopy lists to be run there. However, capacity has recently been lost due to staff shortages and the gastroenterology team needing to support the acute medical take during the second Covid-19 wave. An insourcing company has been identified to provide additional echo capacity at the weekends. This started at the beginning of March 2021. There were delays in establishing an outsourcing contract to increase audiology activity, which is now resolved. The service has been impacted by staff sickness, Covid-19 social distancing and the necessary infection prevention measures.
Access to mental health services
30. Performance is good against standards for increasing access to psychological therapies (IAPT). The Trust exceeded national standards all year across all indicators:
IAPT RTT: percentage of people waiting under six weeks (92.6 per cent in January 2021 against a threshold of 75 per cent). IAPT RTT: percentage of people waiting under 18 weeks (100 per cent in January 2021 against as threshold of 95 per cent). IAPT recovery rates (63.6 per cent in January 2021 against a threshold of 50 per cent).
31. In January 2021, 86.9 per cent of people waiting to be seen by our mental health services were reported as waiting under six weeks, against a required standard of 90 per cent. Compliance in respect of the six-week standard by service area was as follows:
Adults: 95.3 per cent Children and young people’s mental health services: 91.7 per cent Older adults: 71.9 per cent
32. The focus of ongoing improvement work includes:
In cases where patients do not choose a virtual assessment, a face-to-face assessment is offered. Patients/carers have the contact numbers to enable them to contact services should they have any concerns or any circumstances change. All referrals are triaged to assess any risks if patients have to wait. Until normal arrangements resume reducing the number of older adults waiting six weeks or more for mental health services is expected to remain challenging.
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The Trust achieved performance of 61.9 per cent in January 2021 of early intervention in psychosis (people to begin treatment with a NICE-recommended care package within two weeks of referral), which is above the threshold of 56 per cent. Performance has been above the threshold all year.
Yeovil District Hospital NHS Foundation Trust (YDH) operational performance
33. This section summarises operational performance at YDH against key constitutional standards and actions to address underperformance.
Emergency department (ED)
34. Prior to the Covid-19 outbreak, year on year growth for ED was just above 7 per cent (Jan 2020) and had been consistently growing each year. The impact of Covid-19 resulted in ED attendances this year contracting by 22 per cent. Similarly, emergency admissions year-to-date are at -17.03% below trajectory as a result of Covid-19. However, this does not reflect the acuity impact.
35. Latest ED four-hour performance was 91.05 per cent (January 2021). Although below the standard of 95 per cent, ED four-hour performance at YDH is significantly above the national average for trusts with a major ED, which was 70.1 per cent in January 2021. Prior to Covid-19 YDH was consistently achieving the national standard of 95 per cent.
36. Recent ED performance has been impacted by high levels of patient acuity and an increase in mental health presentations.
37. Latest performance against the 15-minute triage time for patients was a median time of 8 minutes (January 2021). YDH consistently maintains good performance for ambulance handovers.
38. The number of 12-hour trolley waits has been maintained at zero all year.
39. The focus of ongoing improvement work includes:
The heralded arrivals pathways (i.e. pre-warning that a patient is being sent: 111 First was launched in November 2020 to support awareness of urgent activity flow into the department). The ED build works which enable the Trust to meet the increase in demand by increasing the ED footprint as well as a new paediatric assessment area and provision for patients who present with mental health issues.
Cancer standards
40. The percentage of patients seen within 14 days of referral by their GP with a suspected cancer was 95.1 per cent in December 2020. The national average was 87.5 per cent. Performance above the national standard of 93 per cent has largely been sustained through the year.
41. The percentage of cancer patients treated within 62 days of referral by their GP was 86.4 per cent in December 2020, which was above the national standard of 85 per cent and above the national average of 75.2 per cent in the same period.
42. The focus of ongoing improvement work includes:
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Patients continue to be prioritised for cancer treatment in line with the national prioritisation codes and timescales. A pan-Somerset RDS referral hub is being established from June 2021 for patients with non-specific symptoms of cancer, but with signs of significant illness. An intention for the continued usage of the St Margaret’s Hospice - Yeovil site - for the provision of oncology services in order to safeguard the safety of patients as a result of Covid-19 management.
Acute referral to treatment (RTT) waiting times
43. All aspects of RTT performance continue to be impacted by the Covid-19 pandemic following the suspension of some elective operations.
44. Prior to the pandemic, YDH maintained consistent delivery of a locally agreed trajectory for RTT which was put in place in order to support equitable waiting times for the whole population of Somerset. The trajectory target varied each month but YDH consistently delivered above 85 per cent prior to the pandemic. The national standard of 92 per cent was last delivered in July 2018.
45. In January 2021, the percentage of patients waiting under 18 weeks RTT was 68.0 per cent. The national average was 67.8 per cent (December 2020).
46. Prior to the Covid-19 pandemic, YDH had zero 52-week wait patients, however, there were 467 people waiting more than 52 weeks for treatment in January 2021. The target is that no one should wait more than 52 weeks.
47. The total waiting list size as at January 2021 was 9,118.
48. The focus of ongoing improvement work includes:
The emphasis during the Covid-19 outbreak is to keep patients safe, with those with urgent conditions continuing to be prioritised. There is an active programme of system-wide actions to support long term recovery and efficient use of available capacity, including aspirational plans to re-configure referral pathways so that capacity is evened out across the county (single points of access project) and/or patients being referred automatically for secondary care advice and guidance as a first step (advice first project).
Diagnostic six-week wait
49. Prior to the impact of Covid-19, YDH maintained consistent achievement of the 99 per cent diagnostic standard, however all aspects of diagnostic performance continue to be impacted by Covid-19.
50. Latest performance (January 2021) was 91.24 per cent of patients waiting less than six weeks for their diagnostic test, which although below the national standard of 99 per cent remains above the national average. YDH performance continues to demonstrate a continuing trend of improvement in recent months.
51. The number of patients waiting over six weeks was 144 in January 2021.
52. The total size of the waiting list was 1,644 in January 2021.
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53. The focus of ongoing improvement work includes:
Capacity has been increased, but social distancing, personal and protective equipment and cleaning measures put in place to manage patient care during the Covid-19 outbreak continue to impact on throughput. An additional MRI van has been supporting the Trust twice a month while work is ongoing to place a permanent second MRI machine in autumn 2021. Ventilation works in endoscopy were completed in late 2020 to ensure that both rooms could continue to be fully functional.
Patient safety performance indicators (YDH and SFT)
54. YDH and SFT treat patient safety with the utmost importance and monitor a range of patient safety indicators to ensure that performance continually improves and that the potential for harm is minimised.
55. A range of patient safety and quality indicators are monitored on a monthly basis within the operational performance reports presented to the Boards of YDH and SFT. An overview against some of the key metrics for January 2021 is provided below (see Figure 72).
Figure 72: Sample Patient Safety indicators – January 2021
SFT YDH Patient Falls 176 105 Pressure Ulcers (Acute – Per 1,000 Bed Days) Data being 0.32 validated C Diff 1 0 E.Coli Gram Negative Blood Stream Infections 2 1 MRSA 0 1 Never Events (Acute) 2 0 VTE Risk Assessment Completed on Admission (Acute) 91.7% 92.60% VTE Risk Assessment Completed on Admission 96.5% - (Community) Number of Same Day Cancelled Operations for Non- 18 2 Clinical Reasons (Acute)
56. The Trusts also maintain incident dashboards which monitor types of incident, numbers, consequences of incidents, feedback and response times.
57. Despite the challenges involved in responding to the Covid-19 pandemic, focus has been maintained on quality and patient safety, and performance against the majority of indicators is stable when compared to the previous year.
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Appendix 5: Early identification of merger projects
1. We have started to identify the clinical and corporate integration projects which we will take forward as part of the proposed merger.
2. Set out below are the driver diagrams created for the previous merger of TSFT/SPFT which created SFT. The driver diagrams (as at November 2020) are included here only to give an indication of the breadth of the underlying programme to deliver the clinical strategy. Aim 1 did not exist at the time of the previous merger so no driver diagram currently exists for that Aim.
3. In addition, we have recently started to develop driver diagrams for acute hospital settings of care for the current merger, and these are also included. These driver diagrams currently identify only those elements which are additional to the SFT driver diagrams, and include the new Aim 1.
4. Our next step is to work as a system to develop county-wide driver diagrams which show the programmes of work to be undertaken by the merged Trust, social care, Somerset County Council and Somerset CCG in order to deliver our 5 clinical care and support aims.
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Aim 2 driver diagram from SFT merger
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Aim 3 driver diagram from SFT merger
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Aim 4 driver diagram from SFT merger
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Aim 5 driver diagram from SFT merger
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Aim 1 driver diagram for YDH/SFT merger (acute hospital-based settings of care elements only)
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Aim 2 driver diagram for YDH/SFT merger (additional acute hospital-based settings of care elements only)
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Aim 3 driver diagram for YDH/SFT merger (additional acute hospital-based settings of care elements only)
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Aim 4 driver diagram for YDH/SFT merger (additional acute hospital-based settings of care elements only)
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Aim 5 driver diagram for YDH/SFT merger (additional acute hospital-based settings of care elements only)
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Support service integration projects
5. In addition, we have a number of support service integration projects that will be taken forward as part of the proposed merger and developed further at Business Case stage. These are set out in Figure 73 below.
Figure 73: Main support service integration projects
Project area Description Procurement Integration of function. Communications Integration of function. Facilities Maintenance / Estates Integration of function, enabling more efficient use of the combined estate. Improvement Complete the integration of the YDH and SFT Improvement teams and deploy PowerHub; finish establishing the Somerset Collaboration Hub Clinical and corporate Governance Bring together governance functions and processes to promote high quality approach to governance and risk management across all sites. Performance Integration of performance monitoring and reporting functions. Digital Development of harmonised IT systems, managed by a single Digital team. People/HR and medical training Integration of HR functions. Development of joint People Strategy, together with OD resource to support cultural harmonisation. Capital development / planning Integration of function Finance Integration of function Research and Development Integration of function Information Governance / GDPR Integration of function Trust HQ services Integration of function
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Appendix 6: Summary integration programme plan 1. Below is a high-level extract of the merger programme plan. The detailed programme plan is provided as a supporting submission to this Case. Appendix 7: Board director profiles
This appendix provides background on the Board Directors of the two Trusts.
Non-Executive Directors – Yeovil District Hospital NHS Foundation Trust
Paul von der Heyde (Chairman)
Paul von der Heyde joined the YDH Board as a Non- Executive Director in June 2012 and assumed the role of Chair of the Audit Committee from June 2013 – April 2016 and the Board Remuneration Committee from March 2014 – January 2016. He began his post as Chairman in January 2016.
Paul was in practice in London for almost 30 years specialising in many clients’ business development following which he has led the UK arm of an international group for 11 years. Paul is also a Fellow of the Institute of Chartered Accountants.
Jane Henderson (NED and Senior Independent Director YDH)
Jane Henderson joined the YDH Board in June 2013.
Jane has held a number of high-profile regional and national leadership roles, including Chief Executive of the South West Regional Development Agency, Regional Director of the Government Office for the South West and Director of Finance and Funding for the Higher Education Funding Council for England. Previous non-executive Board roles include Dementia UK, and Bath Spa University, where Jane was chair of the governing body. Jane is Chair of YDH’s Governance and Quality Assurance Committee and is YDH’s Senior Independent Director.
Martyn Scrivens (NED YDH)
Martyn joined the YDH Board in April 2018.
Martyn is a Fellow of the Institute of Chartered Accountants and chairs the Institute’s Internal Audit Advisory Panel. He has 40 years of experience in audit and risk management, operating at Board level with both the public and private sector. Over the last 15 years he has led the internal audit functions first at a major UK bank and then at a global investment and wealth management bank. From 2010 to 2012, he was a Board member of the East Kent Hospitals NHS Trust. Martyn chairs YDH’s Financial Resilience and Commercial Committee.
Graham Hughes (NED YDH and an observer on SFT Board)
Graham Hughes joined the YDH Board in April 2018.
Graham has over 40 years of experience in the financial and legal sectors and was previously an Executive Director of Bank and Clients PLC. Prior to this, in his capacity as Managing Partner and latterly Chairman, he developed a legal practice to a multi-office large employer. He has a deep understanding of commercial and risk management within the financial sector together with a thorough knowledge of the core strategic principles of heavily regulated and competitive sectors.
He has also been involved in change management, developing policies for large and complex organisations including Whistleblowing, IT Security and Data Protection and People policies. Graham chairs YDH’s Remuneration and Workforce Committees and is a member of the Financial Resilience and Commercial Committee.
Paul Mapson (NED YDH)
Paul joined the YDH Board in March 2020.
After an NHS career spanning 41 years, including 17 years as Director of Finance and Information at University Hospitals Bristol NHS Foundation Trust, Paul retired in June 2019.
He is Chair of YDH’s Audit Committee and member of the Trust’s Financial Resilience and Commercial Committee.
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Executive Directors – Yeovil District Hospital NHS Foundation Trust
Jonathan Higman, Chief Executive YDH
Jonathan Higman joined the YDH Board in January 2009 and became Acting Chief Executive in December 2017. He was appointed as Chief Executive in March 2019. During his time on the Board, he has held a number of Director level posts, including Director of Strategic Development and Director of Operations at the Trust.
Jonathan graduated from the University of Reading in 1993 and has over 20 years’ experience working in a variety of roles in both hospitals and commissioning across the NHS in the South West and South East of England.
Dr Meridith Kane, Chief Medical Officer YDH
Merry Kane joined the YDH Board in December 2019.
Merry graduated from Nottingham University in 1993 and then trained as a Paediatrician with a special interest in Emergency Paediatrics, qualifying in 1996. She gained a Masters Degree in Medical Ethics and Law from Keele University in 2005, and later established the Trust’s Medical Ethics Committee. Merry has occupied a number of management roles at YDH, including Clinical Director of both Emergency Medicine and Paediatrics, Associate Medical Director, and Responsible Officer. She is an alumna of the NHS Leadership Academy, with time spent at Harvard University and the Institute for Healthcare Improvement in Boston, USA.
Merry is passionate in her belief that a well-supported and valued workforce is imperative for the delivery of the best possible care for patients and their families.
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Shelagh Meldrum, Chief Nurse & Deputy Chief Executive YDH
Shelagh Meldrum joined the YDH Board in February 2016.
Shelagh joined YDH with a background in nursing and as a clinical services leader in both the NHS and private facilities. Shelagh began her career in the NHS as a senior nurse working in acute medicine, and subsequently as a senior specialist nurse in neurology. She later became a clinical services lead, managing the six departments, which formed the directorate of specialist medicine. Following a 14-year career in the NHS Shelagh worked as Head of Clinical Services in various independent healthcare facilities. Shelagh previously worked for Circle Healthcare, opening and holding the position of Registered Manager at CircleBath Hospital for five years and then took up the role of Registered Manager at CircleReading Hospital in 2014.
Matthew Bryant, Chief Operating Officer (Hospital Services) YDH
Following the departure of YDH’s Chief Operating Officer, Matthew was appointed to the YDH Board for the period 1 January-30 June 2021 to provide Chief Operating Officer expertise. His role at YDH is similar to his role at SFT where he has day-to-day operational responsibility for community hospitals and Musgrove Park Hospital.
Matthew has worked in the NHS in the South West since 1998, managing medical and surgical services at the Royal Devon and Exeter Hospital, and being part of the management team when that Trust became one of the country’s first foundation trusts. He led the Trust’s delivery of new models of care for older people, which included a strong focus on integration with services outside hospital.
He helped establish the Peninsula Medical School in Exeter, of which he became an Honorary Fellow, teaching undergraduate medical students about healthcare management. He was also involved in the commissioning of specialist services and the development of joint working for health authorities across Devon and Cornwall. Matthew joined the NHS on the national general management training scheme, after graduating from Oxford University. He is also a Trustee of Hospiscare, the palliative care provider for Exeter, East and Mid- Devon.
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Sarah James, Chief Finance Officer YDH
Sarah James joined the YDH Board in October 2019.
Sarah qualified as a member of the Chartered Institute of Public Finance and Accountancy in 1993, through the NHS Graduate Finance Training Scheme. She has worked in a range of finance roles at Salisbury FT, Royal United Hospital Bath FT, Avon and Wiltshire Mental Health Partnership and Wiltshire PCT and joined YDH after 6 years as Chief Finance Officer at Bath and North East Somerset CCG. Sarah has also undertaken roles in corporate governance, project management and performance management.
Jeremy Martin, Director of Transformation YDH
Jeremy Martin joined the YDH Board in February 2020.
Prior to joining the Board, Jeremy was the Programme Director for the Symphony Vanguard Programme, which introduced new integrated models of care for the 150,000 population of south Somerset through a collaboration between primary care, NHS organisations, the local authority and voluntary sector.
Prior to becoming Programme Director, Jeremy was Director of Planning and Performance at Yeovil Hospital, where he led on strategy, planning, performance, communications, IT and corporate governance.
Through his career Jeremy has held a wide variety of roles in NHS organisations and the Department of Health in Somerset and London, including policy development, commissioning, operational management, business development, service improvement and performance management.
Stacy Barron-Fitzsimons, Director of Operations YDH
Stacy joined the YDH Board in January 2021 on a temporary basis for six months to work with Matthew Bryant in overseeing operational delivery. Stacy has over 14 years’ experience and throughout her career has held a wide variety of roles across Acute, Commissioning and Social Care settings, including Contracting, Information and Performance management and Project management.
Stacy has an MBA from Bournemouth University and prior to joining the Board, she was the Deputy Director of Elective Care.
Stacy is passionate about patient access and outcomes and supporting clinical teams to develop and improve services.
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Non-Executive Directors – Somerset NHS Foundation Trust
Colin Drummond OBE, DL (Chairman SFT)
Colin was appointed Chairman of SFT on 1 August 2014. He is also Pro-Chancellor and Chair of Governors of the University of Plymouth. From 1992 to 2013 Colin was Chief Executive of Viridor, a leading recycling, renewable energy and waste management company, and an executive director of Pennon Group PLC. He was then Chairman of Viridor until the end of 2014. Prior to joining Pennon, Colin was Chief Executive of Coats Viyella Yarns Division, an executive director of Renold PLC, a consultant with the Boston Consulting Group and an official with the Bank of England. Colin was Chairman of the Government’s Living with Environmental Change Business Advisory Board from 2009 to 2015 and of the Environmental Sustainability Knowledge Transfer Network from 2007 to 2013.
Colin holds an MA from Oxford University and an MBA from Harvard Business School where he held a Harkness Fellowship. He was appointed an OBE in the Queen's Birthday Honours 2012 for services to technology and innovation, and a Deputy Lieutenant (DL) of Somerset in 2016. Colin was Master of the Worshipful Company of Water Conservators for 2007/08 and Chair of the ‘WET 10’ City Livery Companies from 2008 to 2013. From 1997 to 2015 he was a Trustee, and is now Honorary Vice President of the Calvert Trust Exmoor. He is Trustee of the Water Conservation Trust and President of Wadham College Oxford 1610 Society.
Jan Hull (NED and Deputy Chair, SFT)
Jan Hull spent the early part of her career with Unilever, in an international perfumery business covering sales, marketing and general management roles, including two years in the USA. She has over 20 years’ experience of the NHS in Somerset, initially in Public Health and later as Deputy Chief Executive for NHS Somerset, until she became Managing Director of the South, Central and West Commissioning Support Unit. Jan retired from this post in 2016.
Jan has a good level of knowledge of the services provided by SFT, and the strategic context in which it operates, gained from experience both of directly managing community services, and from her commissioning responsibilities. Jan has worked at senior level with all of the major health and social organisations in the county, including primary care and the voluntary sector. She also has significant experience of structural change, having led the merger of three Commissioning Support Units in 2015.
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Stephen Harrison (NED at SFT and observer on YDH Board)
Stephen joined SFT in 2013. He worked at Clarks Shoes for his main career. On leaving Clarks, Stephen developed a portfolio of organisational development consultancy work and community activity, including being elected as leader of Mendip District Council. In the NHS he has undertaken non-executive director roles with Bath and West Community Trust, Mendip Primary Care Trust (where he was Chairman), North Somerset Primary Care Trust and finally as Chairman of a cluster of PCTs responsible for health services across Bristol, North Somerset and South Gloucestershire.
Stephen is Chairman of YMCA Mendip and is a Trustee of the Lawrence Centre in Wells. He is a governor of Wookey Primary School.
Dr Kate Fallon (NED and Senior Independent Director, SFT)
Kate was appointed as a non-executive director at SFT in July 2015 and came to the Trust with significant experience in the strategic direction and transformation of services within the NHS. She established a completely new NHS trust in 2010, which trebled in size and became the first community trust to be licensed by Monitor as a Foundation Trust in November 2014.
Previously Kate transformed her own general practice, taking it from a traditional reactive business to a forward-planning, innovative “beacon site”, with a sustained Investors in People accolade.
Kate is currently a Trustee of the Workforce Development Trust and Chair of the Skills for Justice enterprise. In 2015 she was included in the HSJ “Top 50 NHS Chief Executives” list for her approach to service transformation and the integration of NHS services.
Barbara Gregory (NED at SFT)
Barbara Gregory has worked at senior management level in the NHS since 1993, including 15 years at Board level in a number of organisations in different parts of the health system – including as a Director of Finance in an NHS organisation. She has an excellent working knowledge gained from first-hand experience of the health and social care system and has also been involved in the Strategic Transformation Programme in Cornwall.
Barbara has also worked closely with senior colleagues from the Local Authority on the integration of provision and commissioning and the opportunities for the devolution of expenditure to providers as part of the potential development of Accountable Care organisations/systems.
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Barbara Clift (NED at SFT and observer on the YDH Board)
Barbara joined SFT as a Non-Executive Director in November 2014, bringing a wealth of experience from the commercial and voluntary sectors and her own business. During her 22 years at IBM, the global technology company, she worked in several business areas at senior level with many corporate clients from multiple industries in the UK and overseas. She held executive responsibility for business segments across Europe, Middle East and Africa. Her work in Africa was recognised with a new women in business award. She attended various executive development courses at INSEAD, Harvard, MIT and Oxford and was active in mentoring and female career development and retention.
After leaving IBM, Barbara worked as a consultant for a not-for-profit sector skills organisation working with schools with a longer-term aim of encouraging girls into the IT industry. She has carried out public sector support engagements as well as starting her own business. She held Trustee positions for charities supporting preventative health, adults with learning difficulties, and a listening ear service for parents who have lost a child. She is currently a Trustee for the Somerset and Wessex Eating Disorders Charity (SWEDA).
David Allen (NED SFT)
David undertook a number of managerial roles within the NHS and has solid experience in acute, mental health and community services, specialising in risk, governance and compliance.
Prior to his work in the NHS, David was a director and Company Secretary at a leading insurance company, with overall responsibility for Information Technology, Human Resources, Facilities, Compliance and Governance.
David is a Chartered Engineer and holds a BSc (Hons) in Engineering and he is a Member of the British Computing Society.
Alexander Priest (NED at SFT)
Following a degree and PhD in chemistry at Oxford University (where he used A.I. to design anti-cancer drugs), Alex started his career promoting apprentice partnerships as chief executive of an educational charity in London. In January 2016, he jumped from a successful career in intellectual property law to become Chief Executive of Mind (the mental health charity) in his home county of Somerset, where he now farms with his young family.
Alex also holds various trusteeships and directorships in the property, education and third sectors.
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Executive Directors – Somerset NHS Foundation Trust
Peter Lewis, Chief Executive SFT
Peter joined SFT in 2005 as Director of Finance and Performance. He became Deputy Chief Executive in 2008 and took on the responsibility of Chief Operating Officer in 2010, before becoming Chief Executive in September 2017. Prior to joining the Trust, Peter was a Director of Performance at Dorset and Somerset Strategic Health Authority and has also worked in both commissioning and provider organisations prior to that.
Peter is a Fellow of the Chartered Institute of Management Accountants.
Andy Heron, Chief Operating Officer (Mental Health and Community Services) and Deputy Chief Executive at SFT
Andy joined SFT in January 2014. He originally qualified as an Occupational Therapist (DIP.COT) and has worked clinically in Cornwall and North Somerset and went on to manage mental health services prior to managing mental health services in Bristol from 1999-2006 where he took a central role in integrating NHS and social care services and a complete service redesign and the comprehensive re-provision of the mental health estate in the city.
Following this Andy gained a broad range of experience in London and the South West in senior commissioning and provider roles in the NHS and also in social care where he worked at the level of Service Director with responsibility for services to people with physical and sensory impairment, learning disabilities and mental health problems. Prior to joining SFT, he was Director of Projects for a successful mental health and community NHS foundation trust in East London with portfolio responsibility for service modernisation and commercial and business development.
Andy maintains a strong interest in care pathway redesign and service integration and is also Lead Director for Restrictive Interventions. Andy is a Director of the Shepton Mallet Health Partnership.
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David Shannon, Director of Strategic Development & Improvement at SFT
David joined SFT as Finance Director in August 2016. David was previously Director of Operational Finance at North Bristol NHS Trust, from June 2014. Before that he spent six years at Nottingham University Hospitals NHS Trust, most of them as Assistant Director of Finance. He originally joined the NHS in 1998 on its graduate financial management training scheme.
David is a member of the Southwest Pathology Services (SPS) Board.
Dr Daniel Meron, Chief Medical Officer at SFT
Daniel joined SFT in December 2019 from his role of chief medical officer of Solent NHS Trust, which provides mental health, community and primary care services to people living in Southampton, Portsmouth and some parts of Hampshire and the Isle of Wight. He was also deputy medical director at University Hospital Southampton Foundation Trust, a large teaching hospital providing secondary and tertiary acute services in Wessex.
Daniel combined senior leadership roles with active front-line clinical work as a consultant in liaison psychiatry in Southampton General Hospital, as well as being actively engaged in research at the School of Medicine, University of Southampton.
Hayley Peters, Chief Nurse, SFT
Hayley has over 25 years of experience in the NHS and joined SFT in July 2013 as the Deputy Director of Nursing. She was appointed as SFT’s Chief Nurse in October 2017.
Prior to that, Hayley worked in senior clinical leadership roles in the south west, London and the south east. Hayley’s early career centred in critical care, first as an intensive care nurse and later, following a period of training at Birmingham Medical School, as one of the first Physician’s Assistants to practise in the UK.
As a senior nursing leader in the south west, Hayley has developed a growing interest in nursing and enabling elderly and frail people to stay safe and reach their full potential through personalised care and service integration. Hayley is passionate about excellence in patient care and aspires to improve patient safety, quality and patient experience.
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Matthew Bryant, Chief Operating Officer (Acute) at SFT
Matthew joined SFT in 2014 as Director of Operations and was appointed as Chief Operating Officer in 2015. He is responsible for the day-to-day running of Musgrove Park hospital and for community hospitals in Somerset. From 1 January 2021 he has taken up a similar role for Yeovil District Hospital.
Matthew has worked in the NHS in the south west since 1998, managing medical and surgical services at the Royal Devon and Exeter Hospital, and being part of the management team when that Trust became one of the country’s first foundation trusts. He led the Trust’s delivery of new models of care for older people, which included a strong focus on integration with services outside hospital.
He helped establish the Peninsula Medical School in Exeter, of which he became an Honorary Fellow, teaching undergraduate medical students about healthcare management. He was also involved in the commissioning of specialist services and the development of joint working for health authorities across Devon and Cornwall. Matthew joined the NHS on the national general management training scheme, after graduating from Oxford University. He is also a Trustee of Hospiscare, the palliative care provider for Exeter, East and Mid- Devon.
Phil Brice, Director of Governance and Corporate Development at SFT
Phil joined SFT in 2012, having worked in the NHS since 2000. He worked for the Somerset Heath Authority before becoming Director of Corporate Services for Taunton Deane Primary Care Trust and then Director of Corporate Services and Communications for NHS Somerset from 2006-2011. He previously worked for the Treasury Solicitor’s department, the Parliamentary and Health Service Ombudsman and AXA PPP healthcare.
He was appointed as SFT’s Director of Governance and Corporate Development in October 2017. He is a Director of the Shepton Mallet Health Partnership.
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Pippa Moger, Director of Finance at SFT
Pippa joined the NHS in 2002 as a management accountant at South Somerset Primary Care Trust where she remained employed until the restructuring of primary care trusts in 2007 by which stage she had been promoted to Assistant Director of Finance. In 2007 Pippa joined NHS South West as Assistant Director of Finance responsible for strategic development of costing and payment by results for the South West. During her time at NHS South West a secondment opportunity arose in NHS Wiltshire to head up the commissioning team for 6 months.
In March 2009 Pippa joined Yeovil District Hospital NHS Foundation Trust as Assistant Director of Finance and on leaving the Trust in 2013 had been Interim Director of Finance.
Pippa has a passion for ensuring that NHS resources are used in the most efficient and effective way whilst ensuring patient safety is not compromised.
Pippa is a Director of the Shepton Mallet Health Partnership.
Isobel Clements, Director of Director People and Organisational Development at SFT
Isobel started her career at Musgrove Park Hospital in 1988 and held several senior human resources and organisational development management roles, including at associate and deputy level, until she became Director of People at SFT in 2014 (operating at a deputy level).
She has played a key role in developing the Trust’s system of distributed leadership, in ensuring that the organisation’s values are brought to life in everyday behaviour, and in overseeing a leadership programme in which over 900 colleagues at the hospital have now taken part.
Isobel was appointed as SFT’s Director of People and Organisational Development in November 2017. Isobel is a member of the Chartered Institute of Personnel and Development.
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Appendix 8: Assessment criteria and sub-criteria for options appraisal
Proposed criteria Sub criteria Features of a high scoring option Features of a low scoring option Patient and Impact on safety and Opportunity for improvement in safety Opportunity for improvement only across service user quality of care and quality across all services (acute, some services / pathways or risk that impact: impact on community, mental health and primary quality deteriorates e.g. through weaker safety and quality care) e.g. through addressing subscale ward to board links / lack of clear lines of of care, patient acute services or providing greater accountability. and service user opportunity for sharing best practice experience and and peer review. long term health Organisational barriers prevent full outcomes Ability to align resources (capital sharing and alignment of resources investment, facilities, workforce) to the (capital investment, facilities, workforce) areas of greatest impact from a safety to the area of greatest impact. and quality perspective. Scale of case for change provides less Ability to attract capital investment to opportunity to attract investment support the areas of biggest need compared to other regions. across the population/county through a shared clinical strategy and case for change.
Impact on patient and Supports delivery of consistent high Organisational barriers exist to the service user experience quality patient and service user development of seamless pathways of experience across the county by care, regardless of setting. removing gaps (and duplication) through seamless pathways of care, regardless of setting. Access to care varies by patient / service user location. Provides equity of access regardless of patient / service user location (e.g. allowing patients to access elective treatment more quickly by pooling Organisational barriers to investing resources). resources where they are most needed e.g. to create new services in areas where Enables delivery of care as close to the there are gaps in provision. patient / service users’ normal place of residence as clinically possible. Impact on long term Enables greater sharing and direction Organisational and cultural barriers health outcomes of resources to the area of most impact remain to sharing and direction of for the long term health outcomes of resources to the area of most impact on the local population (e.g. through health outcomes, e.g. through a focus on ability to invest in early intervention investment in acute services. and prevention).
Facilitates the direction of resources to Organisational and cultural barriers tackle health inequalities (eg arising remain to tackling health inequalities. from mental health status, socio- economic status, ethnicity, gender, Centralisation or standardisation of disability etc). services limits the provision of services that are tailored to the local population Supports localised provision that is needs. tailored to the local population needs.
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Strategic Supports the Provides sufficient governance for Additional governance would be required alignment: fit development of the operation of an ICP/ lead provider to operate an ICP /lead provider with national, STP Somerset ICS and ICP arrangement and enables stronger arrangement or does not strengthen and Trust level partnership working with primary, partnership working. strategies, social care and voluntary sectors. including development of Enables delivery of the Single strategic leadership with Clinical service decisions still need to be neighbourhoods joint clinical strategy accountability for decision making on ratified by both Trust Boards. and creation of an clinical strategy. ICS and ICP Supports the Facilitates neighbourhood working, Significant risks to effective MDT working development of aligned to PCNs, including the tailoring remain. neighbourhood working of services to meet the needs of the aligned to PCNs local population where appropriate.
Reduces barriers to effective MDT working in neighbourhoods, for example through closer working with primary, social care and voluntary organisations.
Enables system wide Allows system-wide support strategies Barriers remain to effective attraction of estates and digital to be developed more easily, which capital investment (due to scale) and the strategies attract capital investment and enable utilisation of funding across the whole funding to be deployed where it is estate most needed without barriers
Scales SFT’s GDE status and spreads tried-and-tested digital innovation Digital is not able to be scaled to the same across the county degree
Clinical Impact on subscale Ability to improve long-term resilience Continued workforce challenges in sustainability: services and resilience by sharing rotas or combining services subscale services. impact on clinical to reduce reliance on single/few sustainability individuals. (including subscale services), Ability to flex resources at pace (staff Barriers to rapid redirection of combined performance and and estates) during short periods of resources during periods of pressure. Trusts’ resilience high pressure. Fragmentation of clinical teams / Ability to support primary care which is expertise across the county limits ability fragile in some parts of the county. to support primary care.
Impact on performance Ability to direct resources (capital Organisational barriers to directing investment, facilities, workforce) to the resources to the areas of greatest need areas of greatest need from a from a performance perspective as performance perspective (e.g. elective performance continues to be regulated for surgery) to improve overall individual organisations. performance. Focus on organisational change distracts from focus on business as usual.
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Financial Delivery of financial Enables delivery of significant financial Delays or reduces level of financial sustainability and benefits that are benefits, e.g. through scale, aligned benefits that can be achieved value for money: greater than the do decision making and delivery capacity Benefits that can minimum and capability. be achieved relative to the Reduces management / running costs. Increases management / running costs. cost of Cost of implementation Low costs of implementation High costs of implementation implementation. Impact on both Sustainability of Increases financial sustainability of Providers remain subscale and retain Trusts’ financial individual providers and providers and overall health and care significant deficit position. position and the the overall health and system overall financial care system sustainability of the Somerset health & care system.
Workforce and Enables development Provides a more diverse offer to Barriers to staff portability between culture impact: and implementation of colleagues including career path, organisations, for example due to impact on a Somerset health and training offer, portfolio careers and misaligned workforce policies. workforce care system workforce locations (enabled through aligned challenges, strategy / people plan workforce policies). including recruitment & Ability to succession plan for leadership Succession planning likely to be limited to retention and roles within Somerset system. individual organisations. colleague wellbeing and the Supports recruitment and retention. Limits recruitment and retention in the ability to retain long-term. positive local Impact on colleague Greater access to resources including Access limited to the resources available cultural identity. satisfaction and training & development, wellbeing and within existing organisations. wellbeing occupational health. Impact on culture and Ability to develop a shared culture and Positive and cherished local identities local identity approaches for Somerset whilst might be lost if approaches are retaining positive and cherished local standardised without consideration to identities. local circumstances.
Deliverability: Ease of implementation Is supported by the majority of Significant resistance from a number of ease, cost and stakeholders, including NHSEI. stakeholders. pace of benefits delivery as well as Sufficient executive / leadership Significant concerns exist as to executive / ongoing operation capacity and capability to deliver. leadership team capacity and capability to (e.g. efficient deliver. governance, Low complexity associated with running costs) implementation. High complexity associated with implementation (e.g. regulatory approvals). Pace of benefits Enables benefits delivery within Significant delays possible to proposed delivery timeline and benefits delivery. national and local deadlines for
creating a Somerset ICS. Ongoing operations Allows for more streamlined Creates additional levels of governance governance arrangements and efficient and bureaucracy and results in operation of the organisation. operational inefficiency, e.g. dual structures / reporting.
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Appendix 9: Principles for our joint Estates Strategy
Principles for our Estates Strategy
Our estates will:
Work for the people that use them Help to deliver our clinical strategy Be safe, well maintained, effective and welcoming Support our aim to value all people alike Reflect our design aspirations
Principle: Ensuring that the health estate meets the objectives of the clinical strategy through promoting safe, effective, high quality care delivered in the most appropriate setting and through enhancing health and wellbeing.
All healthcare environments are designed to ensure patient and colleague safety, with safety taking precedence over all other design considerations. Everyone is supported by a high quality, therapeutic environment that delivers confidence, dignity, physical and mental well-being. Our estates will promote equity and inclusivity, making everyone feel welcome and valued. The patient environment is designed to ensure that patients and their families/others have access to well designed, safe outside space. Services need be located near to patient homes in appropriate community settings whenever this is the right thing to do, meaning that only those services that need to be based in hospital settings are based in hospital settings. The future development of the healthcare estates should ensure that the views and aspirations of our patients and the wider community are reflected in all our healthcare environments, and wherever possible estates are co-designed and conceived. Our estates will facilitate the treatment and support of people with complex needs including those with dementia, learning difficulties and other forms of disability. The estates should support the carers’ charter, making it easy for carers to provide care. Our built environment will pursue high standards of effectiveness in order to drive efficiency and to reduce the time that patients need to spend in health care settings. Planning of services and health care environments will include the benefits of digital technology. Our estates will facilitate colleagues and patients to make the right choices by making these choices the easiest options to take. Opportunities will be identified to ensure that the development of our healthcare estates benefit from learning about current best practice and cutting edge, innovative design solutions.
Principle: Ensuring that the health estate promotes colleague wellbeing and productivity
All healthcare environments are designed to ensure safety for everyone.
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Facilities for promoting colleague well-being will be high quality and evidence based, ensuring colleagues feel valued. The environment is designed to ensure that everyone has access to outside space which will include areas to enhance resilience and reduce stress for our colleagues. We will place a high priority on training and education facilities. Dedicated social spaces will be provided that do not compromise patient confidentiality. Our built environment will pursue high standards of effectiveness in order to support the delivery of patient care and improve colleague productivity and reduce stress.
Principle: Ensuring the current health estate is fully and effectively utilised and reducing estate where it is not required or not cost effective to maintain The use of the Trust’s estates is prioritised for those services that cannot be provided or delivered through agile working arrangements. Where appropriate modern working practices that improve workplace productivity should be adopted that maximise the utilisation of the estate, this might involve open planning work with workstations suitable for flexible working. As part of the development of new models of care, where surplus estate is identified then disposal opportunities should be explored. Opportunities for working with other public and voluntary sector organisations to optimise the use of the public estates should be actively pursued. The use of our fixed assets is maximised, with the intention of moving towards 7-day utilisation.
Principle: Ensuring that current health estate is fit for purpose Improvements to the estate should be designed to ensure flexibility and resilience to adapt to a range of functions and enable separation of flows. Healthcare is undergoing continuous change. Our healthcare environments should be designed to be as flexible and adaptable as possible to respond to the changing requirements of healthcare provision. Sufficient investment should be made in the estate to reduce the risk of infrastructure failure. Capital investment plans should aim to eliminate backlog maintenance where national capital funding allocations allow.
Principle: Reducing the running costs of the health estate to enable better use of resources The future development of estates should optimise low carbon technologies that assist with achieving a net zero carbon future targets for the NHS by 2030. The future development of the estate should take account of the whole life cycle cost as part of any investment decisions. The built environment will promote effective people-centred pathways, and should enhance effectiveness to drive efficiency.
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