Scrutiny of the Budget Proposals 2011/12

Appendix 5A

SCRUTINY OF THE BUDGET PROPOSALS 2011/12: The service and financial challenge for the local NHS over the next four years

KEY QUESTIONS

Group 1 – STRATEGY & ENGAGEMENT

1.1 What is the strategy behind the budget proposals? What are the main policy issues over the medium-term? How are the budget priorities consistent with the DH Operating Framework/Monitor?

East and North Hertfordshire NHS Trust

The overall strategy for the health system will be to operate with minimal levels of real terms growth over the period and to continue to maintain current performance standards.

The Trust’s financial strategy in its 5 year Long Term Financial Model is consistent with the current DH Operating Framework and Monitor’s guidance and assumptions.

NHS Hertfordshire

The budget proposals are based on the PCT’s refreshed Strategic Plan which was approved by the two former Hertfordshire PCT Boards in January 2010. This reviewed and refreshed the five-year strategic plan (which was published in March 2009) to take stock of progress made so far and the major change in the economic position which was affecting prospects for public sector expenditure and investment. The Strategy is based upon three strategic goals:

 Keeping Hertfordshire healthy  Enhancing the patient experience  Commissioning high quality health care

Underpinning these goals is a series of workstreams, each of which has specific outcomes and action plans whereby achievement and progress are measured. These include the key clinical priorities in Towards the Best Together, the East of England response to the national Next Steps Review. At the heart of the refreshed strategy, however, remains Delivering Quality Healthcare for Hertfordshire (DQHH), a whole systems approach to future service design and delivery, subject to public consultation in 2007. A key objective throughout is to move appropriate aspects of healthcare provision closer to home, away from acute hospitals to delivery in people’s houses or in more local facilities.

1 Hertfordshire Partnership Foundation Trust

The Trust is committed to providing excellent health and social care for both people with mental ill health and those with a learning disability. We aim to provide services which make a positive difference to the lives of service users and their carers, underpinned by the principles of choice and independence, delivering high quality, safety and ensuring sustainability. The partnership arrangements with the local authority provide an excellent opportunity to develop a recovery orientated approach based on holistic assessment of both health and social care needs.

The White Paper Equity and Excellence: Liberating the NHS sets out the Government’s strategy for the NHS. The intention is to create an NHS which is much more responsive to patients, and achieves better outcomes, with increased autonomy and clear accountability at every level. The key themes are:

 Improving public health, tackling health inequalities and reforming social care  Putting patients and the public and patients first, increasing choice and control  Improving healthcare outcomes, implementing quality standards  Increasing autonomy, accountability and democratic legitimacy  Cutting bureaucracy and improving efficiency

The 2010/2011 NHS Operating Framework focuses on and reaffirms five national priorities, or ‘vital signs’:

 Improving cleanliness and reducing infection  Improving access and reducing waiting  Maintaining well-being, improving health and reducing health inequality  Improving patient experience, staff satisfaction and engagement  Being prepared for emergencies

These dovetail with the devolved responsibilities of the Trust in delivering integrated health and social care reflecting the ‘Putting People First’ agenda including:

 Personalisation of Care  Services to lengthen independence – prevention and early intervention  Safeguarding adults and children  Improving access to services

HPFT has drawn these together with previous proposals around ‘Investing in Your Mental Health’ in Hertfordshire to develop a significant service transformation programme entitled ‘Leading by Design’.

Our vision is: ‘To be the leading provider of mental health and specialist learning disability services in the country’. At its core this means delivering the highest quality care with excellent treatment outcomes, within a safe environment which meets the needs of service users and carers.

2 This is underpinned by eight key goals, which can be categorised under three headings:

 Customers and the community - the delivery of high quality integrated care to our customers and communities  People - ensuring that we have a highly skilled and motivated workforce  Sustainability - our ability to develop and sustain the organisation for the future : Customers and Community 1. To deliver high quality integrated health and social care services in accordance with recovery principles 2. To be the provider of choice for service users, carers, the community and commissioners 3. To work in partnership with the community to promote the wellbeing of others, whilst making a positive contribution to the environment 4. To be the employer of choice where staff are highly valued, well supported and rewarded

People 5. To create a dynamic and flexible working environment where staff are motivated and committed to providing high quality care 6. To embed a culture of learning where staff develop their full potential and deliver excellent care

Sustainability 7. To ensure a sustainable future through income growth and the efficient use of resources 8. To be an innovative and learning organisation that embraces new and modern approaches to health and social care.

Leading By Design is our four year programme to turn this vision into reality. It will transform how we work and deliver services. Its scope encompasses all of the trust’s activities and everyone who works for the trust. At its core is the need to deliver:

 Consistently excellent care and treatment outcomes that promote recovery and meet the personal needs and expectations of service users and carers  Productive and efficient services that meet the funding pressures facing the NHS and secure the Trust’s future

This will be done through service transformation, enabling simpler, faster access and clear, coordinated journeys.

West Hertfordshire Hospital Trust

The Trust’s Financial Strategy is to:

To maximise operational efficiency Generate sufficient cash to service debt Reshape & maintain the Trust’s estate to support delivery of changing patient services

3 The Financial Plan incorporates the most recent planning assumptions available from Monitor, EoE SHA, other national targets set out in the 2010/11 DH operating framework, and local targets included in PCT’s plans / QIPP approach. It also reflects the economic conditions going forward, incorporating any known Government plans at the time, for example the Emergency Coalition Government Budget. The DH operating framework for 2011/12 is expected mid-December and changes will be reflected in a revised LTFM.

This information is contained within the Trust’s Integrated Business Plan (IBP) and Long Term Financial Model (LTFM). Negotiations that would result in any changes to this for the 2011/12 budget are based on discussions with the commissioners, currently the PCT.

Hertfordshire Community NHS Trust

HCT is seeking to set budgets which fulfil its financial duties as an NHS Trust while underpinning its core strategy of being the provider of choice for community health services across the county.

The main policy issues focus upon our part in NHS Hertfordshire’s “DHQQ” plan, which in turn is reflected strongly in the “QIPP” plan. This promotes providing care “closer to home” substituting acute referrals with community settings wherever possible. A significant element centres on the PCT’s intermediate care strategy and determination of the number of beds and sites required and the mix of providers involved.

1.2 How have the proposals been informed by public/partner engagement? How are users/carers/young people being engaged to develop the service in line with the budget proposals?

East and North Hertfordshire NHS Trust

The Trust works in close partnership with NHS Hertfordshire to identify and develop the services required for the local population, within the agreed Our Changing Hospitals programme, service, operating and budgetary frameworks.

We engage regularly with key stakeholders and stakeholder groups such as local MPs and council leaders, Local Involvement Networks (LINks), Local Strategic Partnerships (LSPs) and county / district / borough council health working groups, to discuss service plans and partnership working. We also engage with these groups collectively through the Trust’s Involvement Committee which provides an additional forum that enables stakeholders, and through them, the wider community to be informed of and involved in the planning, monitoring and shaping of the Trust’s services and to support continuous improvement in line with the Trust’s strategic aims. It also allows members to share local priorities and identify areas that the group can work on collaboratively.

4 Service development and improvement initiatives are discussed and developed through engagement with GPs and Practice Based Commissioning (PBC) leads through the Clinical Engagement Forum which meets bi-monthly and includes Trust clinical and senior management personnel as well as PCT managers. It provides the main forum for Trust clinicians to network with senior representatives from the clinical community, to share information, concerns, ideas and plans on a regular basis. The forum has a formal responsibility to foster and facilitate clinical collaboration across the patch to deliver high quality healthcare and strategic priorities. Engagement with GPs is additionally supported through PBC locality and practice meetings attended by Trust clinicians and strategic development staff, facilitated by a proactive relationship management approach.

All patient experience data are incorporated into performance management processes and are monitored by the Patient Experience Steering Group. This group delivers the Trust’s Patient Experience Strategy which is used to drive continuous improvements in the quality of services being delivered, progress against which is measured by the Risk and Quality Committee which reports to the Trust Board. A great deal of emphasis is placed on patient feedback through real-time (Patient Experience Trackers) and postal surveys, as well as complaints and comments received through PALS, NHS Choices and other channels which are directed to the appropriate teams for investigation, follow-up and resolution. The Trust’s Patient Panel meets bi-monthly and provides a forum that involves patients, carers and members of the public in the development and planning of new services. They also act as a ‘critical friend’ by providing feedback and comments on the quality and provision of services to help inform and support future design and development of services.

The current OCH Programme has involved significant public consultation on service developments eg. trauma and orthopaedic services, maternity services, car parking and access issues, to help inform service developments. The process for public consultation is well established and effective, utilising workshops, design review / development panels, displays in hospital thoroughfares, consultation documents, briefings, press releases and focus groups.

In addition, as part of our application to achieve Foundation status, the Trust is recruiting 8,000 public members (we currently have around 7,000) who will be able to influence and help inform how we develop our services moving forward. As well as ensuring membership is representative of the local population, the Trust is proactively targeting ethnic groups and young people (minimum age for membership is 14) to encourage them to get involved. These members will be represented by a Council of Governors, consisting of members elected from the public membership constituency as well as staff groups and appointed governors from key partner and stakeholder groups; collectively, they will represent the views and interests of local communities to make sure that the Trust Board takes those views into account. They will be able to influence decisions about spending and

5 priorities for investment and service development and be formally consulted by the Board on forward plans.

NHS Hertfordshire

The underpinning strategy, Delivering Quality Healthcare for Hertfordshire (DQHH ) was developed through detailed engagement and public consultation in 2007. Its implementation has been regularly scrutinised by the Health Scrutiny Committee and at various stages and for specific service redesign further engagement with partners and the public has taken place.

NHS Hertfordshire is a partner in the Hertfordshire Public Engagement Partnership; has a well-established stakeholder forum chaired independently; patient/carer groups to shape and influence service change as well as using specific engagement techniques such as conversation cafes for bringing together a cross section of public, voluntary sector and local authority partners.(Example- intermediate care strategy)

Hertfordshire Partnership Foundation Trust

We have built our plans for the Leading by Design programme through first developing a clear understanding of the future requirements of our key stakeholders. We have:

 Worked actively with commissioners to align the priorities of our transformation programme with Investing in your Mental Health in Hertfordshire and specific engagement for people with a learning disability  Held discussions with and attended several workshops with people with a lived experience either as service users or carers  Held discussions with GPs to discuss their perspective of local needs, preferences and requirements  Held several engagement events with staff working with people from all care groups and other key stakeholders underpinned by a communications and engagement strategy with a range of channels including cascade, staff intranet and e-mail

Leading directly from these discussions we focused our work on two broad areas: 1. Access to services, and 2. Pathways through and out of services. We developed potential service models based on the requirements of each. These were then tested to assess the likely benefits, risks and feasibility. The work around each area was clinically led and informed by international as well as national evidence and best practice.

Engagement with key stakeholders will continue to play a central role as we develop our plan further. The philosophy and the rationale need to be understood as well as the proposed service design. It is anticipated that the design will be refined in partnership with key stakeholders over the next three months. To enable this to happen, 13 workshops have been organised throughout the end of November and the start of December, with GP and local events through to January 2011. These will enable the

6 Trust to further engage key stakeholders with these developments, and allow them to comment and shape further development of these ideas, allowing an assessment of the available options.

Examples of engagement include:-

 In July around 100 delegates gathered to provide ideas about how mental health services in the county could be improved, to make them more reflective of what service users and carers say they want and need. The event was organised as a follow up to the Alliance Survey 2009 where over 480 service users and 150 carers gave their views of mental health services whether provided by the Trust or the third sector, highlighting many areas for improvement. The Hertfordshire Local Involvement Network (LINk) organised the event working closely with the Trust and commissioners, and it was facilitated by the National Development Team for Inclusion, the event focussing on solutions not problems.

Ideas for the future of Older People’s Services in Hertfordshire were recently the focus of a stakeholders’ day. And HPFT welcomed about 50 people to share ideas about Older Peoples Services in Hertfordshire. HPFT Older People’s Services Staff were well represented but in particular there was key involvement from The Red Cross, Age UK, Carers in Herts, Alzheimer’s Society and Adult Care Services. The event offered carers, staff from HPFT and partners from voluntary organisations the opportunity to experience presentations about the future of Community Teams, Day Assessment and Treatment Services and Inpatient Units. This stimulated lively discussion in groups and feedback followed to ensure delegates had the opportunity for their views to be heard regarding the redesign of Mental Health Services for older people. Key themes discussed focussed on quality, sustainability and efficiency. The day generated excellent feedback to inform the redesign work currently taking place in Older Peoples Mental Health Services.

 The LGBT Health Summit 2010 is the largest national event focused at improving health and social care in the UK for Lesbian, Gay, Bisexual and Transgender (LGBT) people. The Trust hosted the 2010 summit in Hatfield during September, attracting 340 delegates from all across the UK – and Europe. The theme set by the Trust was to focus on the emotional health needs of LGBT people and the relationships with physical health. These were highlighted by keynote speakers, including Paul Farmer, Chief Executive of national MIND and Helen Jones from MindOut talking about the barriers faced by LGBT people and the disproportionate rates of mental illness amongst these groups.

7 West Hertfordshire Hospital Trust

The Trust consulted on these proposals over a 16 week period with over 30 meetings held. The responses to our consultation resulted in some changes to our constitutional boundaries.

We communicate with our membership, both staff and public, through regular newsletters and in the active recruitment of Governors.

This includes active partnership with:  Local Involvement Networks (invited to be a Governor)  Local Councillors  University of Hertfordshire  Officers of the council  PCT  GP forum – clinical conclave…  Regular meetings with local MPs  Attend local health groups such as Dacorum, ST Albans and Watford

The Trust Board receives regular reports on quality and financial performance, which are public documents, published on the website and made readily available in hard copy.

The Trust issues regular press releases on activities within the trust and actively uses hospital radio. The trust is improving the soft intelligence contained in the NHS choice website and meets regularly with editors of all the local news groups.

Specifically commended in HDD for our relatively good representation of 18 – 24 year olds, 19% compared to a national target of 14%.

The Trust also has the following groups in place:

Patient Improvement & Experience Group, listening to the patient voice through representation, which is then actively used, e.g., in the review of in and out patient surveys

Patient Panel, which reviews all patient information in conjunction with Trust Information Policy, e.g. the redesign and content of patient directed letters

Young Carers Reference Group / Carers Working Group.

Hertfordshire Community NHS Trust

A representative from LINk'S serves as a lay member of our Board. We also review the results of the patient’s survey with great attention and build these into future plans.

8 1.3 How are staff in the service being engaged to ensure that their ideas and suggestions are heard?

East and North Hertfordshire NHS Trust

All of our budget managers are required to support the development of financial plans, including cost improvement programmes within operational divisions / clinical specialties.

In terms of the wider group of staff, the Trust is embarking on a major exercise to gauge the views of staff and obtain suggestions as to how the organisation could be more productive and/or save money.

NHS Hertfordshire

Following the establishment of Hertfordshire Community Trust, NHS Hertfordshire is now a totally commissioning organisation. It has a staff intranet (The Zone), a regular staff bulletin (Hertbrief); uses screensavers on all staff PCCs as well as staff noticeboards. The Chief Executive and Directors hold staff meetings.

The PCT has also adopted a Programme Management Office (PMO) approach. The PMO is a meeting of senior managers which takes place every morning to monitor our performance in key areas, test out new ideas and to agree next steps on major projects and areas of work. It is also a really useful way that important information on what’s going on can be shared with other people. It means that teams work more effectively together.

Hertfordshire Partnership Foundation Trust

See 1.2

West Hertfordshire Hospital Trust

Staff are fully involved in identifying and managing the solutions required to develop services, through the business planning process. Innovation is encouraged with quality improvement as the first priority and ensuring that patient safety is never compromised.

Open door sessions are held monthly on every site, where staff are encourage to attend and discuss any of their issues with a Executive Director. In addition Executive Directors make regular visits to areas of the Trust to talk with staff as well as patients about their experience.

Regular sessions are held with staff, on the savings programme where ideas for further opportunities are raised and discussed.

The Trust has dedicated web addresses of Info@ and rumours where staff can raise issues anonymously.

9 There is regular communication with all staff, the CEO holds regular face to face staff briefings and produces a regular podcast to all staff. In addition there are:

 Week in focus – weekly staff communication via email  In Touch - Monthly, attached to all wageslips  Membership Newsletter - monthly communications to all members both public and staff  Management Matters - bi-monthly to senior managers as a cascade tool  On the pulse – a quarterly glossy magazine, widely distributed Around the Wards - 3-times a year, published in the Watford Observer as a 4-page pull out.

Hertfordshire Community NHS Trust

The Chief Executive conducts regular road shows which involves opportunity for front line staff to make their proposals. Our intranet also contains a facility for suggestions.

We are investing in projects involving “Lean” methodologies with our teams which encourage identifying scope for efficiency and improving the patient experience.

1.4 How are the wider benefits of partnership working (to users/carers and greater efficiency of the system) reflected in the budget proposals?

East and North Hertfordshire NHS Trust

See 1.2 above.

NHS Hertfordshire

See also 1.2. NHS Hertfordshire has developed closer links with partners in areas such as joint commissioning of MH & LD; intermediate care and enablement as well as with district LSPs regarding the Keeping Hertfordshire Healthy agenda (smoking cessation and obesity).

Hertfordshire Partnership Foundation Trust

Our plans are supported by measurable objectives which will allow us to monitor progress against key goals for partnership working, for example these include:

 Work in partnership with local organisations to reduce stigma and improve mental health wellbeing , developing an anti-stigma campaign in collaboration with Governors and Members  Work with NCPC, primary care and academic partners to develop an end of life pathway for people with dementia in line with the national dementia strategy.  Provide seamless health and social care by working in partnership across the care pathway

10  Develop new Mental Health Promotion and Suicide Prevention strategies in partnership with the PCT, JCT and third sector

The Hertfordshire health economy has developed a coordinated county wide joint QIPP plan across the five health organisations. This has been shared and agreed with East of England, with a further version to be produced in January, subsequent to the publication of the coalition’s revised operating framework. Further the Trust is actively engaged in the East of England wide QUIP initiative to both contribute and benefit from system-wide efficiency opportunities.

West Hertfordshire Hospital Trust

An integrated business plan informed by partners, stakeholders, patients and membership and our budget proposals are based on:

 Commissioners’ intentions determined by the contract negotiation process,  Workforce plans,  Service development plans,  Resources available

Hertfordshire Community NHS Trust

The Community Trust works in partnership with ACS and with the county wheelchair service.

How has the right level of reserves/balances/contingencies been determined? Is the Treasury Management Strategy appropriate?

As a newly established Trust, HCT has had to define its own financial strategies. A strong balance sheet has been established providing a positive level of working capital. The PCT has provided sufficient cash for the new Trust to support its initial financial obligations. A cash flow budget has been constructed.