Poole NHS Foundation Trust

Use of Resources report Date of site visit: Road, , Dorset BH15 2JB 6 October 2017

Tel: 01202 665511 Date of publication: www.poole.nhs.uk 2 August 2018

This report describes NHS Improvement’s assessment of how effectively this trust uses its resources. It is based on a combination of data on the trust’s performance over the previous 12 months, our local intelligence, the trust’s commentary on its performance, and qualitative evidence collected during a site visit comprised of a series of structured conversations with the trust's leadership team.

How effectively is the trust using its resources? Good 

How we carried out this assessment

The aim of Use of Resources assessments is to understand how effectively providers are using their resources to provide high quality, efficient and sustainable care for patients. The assessment team has, according to the published framework, examined the trust’s performance over the previous 12 months against a small number of initial metrics, alongside local intelligence from NHS Improvement’s day-to-day interactions with the trust, and the trust’s own commentary and information on its performance. The team conducted a dedicated site visit to engage with key staff using key lines of enquiry (KLOEs) and prompt questions in the areas of clinical services; people; clinical support services; corporate services, procurement, estates and facilities; and finance. All KLOEs, initial metrics and prompts can be found in the Use of Resources assessment framework.

We visited the trust on 6 October 2017 where we met the trust’s leadership for discussions based on key lines of enquiry and prompts. The participants included the executive team (including the Chief Executive), a non-executive director (in this case, the Chair) and relevant senior management responsible for the areas under this assessment’s KLOEs.

20171123 Poole Hospital NHS FT Use of resources October 2017 1 Summary of findings

Is the trust using its resources productively to Good  maximise patient benefit? We rated use of resources as Good because the trust is achieving good use of resources, enabling it to provide high quality and sustainable care for patients:  For the year ended 31 March 2017, the trust reported a surplus of £0.9m, which exceeded the trust’s plan and the target (referred to as the ‘Control Total’) set by NHS Improvement. The trust is on track after the first three months of the 2017/18 financial year to deliver its Control Total of £3.1m deficit. This means that the trust is meeting its overarching financial obligations as set out by NHS Improvement.  The trust manages its finances so that it is not reliant on extra cash support in order to meet its obligations.  The trust spends less on pay and other goods and services per weighted unit of activity (WAU) than most other trusts. This indicates that the trust is more productive at delivering services than comparable trusts by showing that, on average, the trust spends less to deliver the same number of services.  The trust is working with Dorset Clinical Commissioning Group (CCG) and other NHS providers in Dorset to implement the Dorset Clinical Services Review which will lead to the trust focus being on planned care in the future.  The trust demonstrated examples of innovation and good practice, including its work with the Local Authority on discharge processes, use of allied healthcare professionals (AHPs) in the Musculo- Skeletal pathway, focus on its medicines programme, the involvement of clinicians in procurement, and its financial management. The trust also outlined areas in which it has already worked with other health bodies in Dorset to get better value for money through joint procurement exercises.

However:  The trust is planning to move from a balanced budget to a 1.3% deficit position by the end of the 2017/18 financial year. It also believes its long term financial sustainability as a standalone organisation is uncertain.  The trust is not currently meeting the national operational performance standard for A&E, in August 2017 the trust achieved 91.7% against the 95% standard.  Further work is required with its population to consistently reduce Did Not Attend rates.  Benchmarks for doctor and AHP costs are high, with the trust in the highest cost quartile for these pay areas per WAU. This metric suggests that the trust needs to do more work to understand whether this is a warranted variation for the services it provides.

How well is the trust using its resources to provide clinical services that operate as productively as possible and thereby maximise patient benefit?  Fewer patients are coming into hospital unnecessarily prior to treatment compared to most other similar in England. The trust is performing in the lowest (best) quartile compared to national averages and its peer group in relation to pre-procedure non-elective days, and is looking at ways of improving this further, eg the fractured neck of femur pathway is being reviewed to increase the percentage of patients treated within 36 hours.  Performance is above (better than) the median for elective pre-procedure bed days, and the trust is reviewing cases where patients have been brought into hospital the night before a procedure to identify further improvements to reduce the incidence of where this is clinically unnecessary.  Patients are less likely to require additional medical treatment for the same condition at this trust compared to similar trusts. Readmission rates at 7.06% in the first three months of 2017/18, compare well (better than median) against peers.  The most recent information (August 2017) shows the trust met its core operational performance standards for Referral to Treatment and cancer, however it did not meet its A&E performance standard, with 91.7% of patients being admitted, transferred or discharged within 4 hours of arrival at the A&E department against the 95% standard.

20171123 Poole Hospital NHS FT Use of resources October 2017 2  The trust reports a fluctuating position for Outpatient Did Not Attend (DNA) rates, however the most recent data, (at 7.42% for the first three months of 2017/18) is better than the median when compared to the national average, with a rate of 7%. The trust has an improvement plan in place, under which it is working to avoid multiple changes to appointment times, and is reviewing data to identify the themes and trends of non-attendance relating to administrative processes.  The trust reports a higher than target Delayed Transfers of Care (DTOC) rate of 3.75% (August 2017), however there has been an overall downward trend in DTOC rate over the last 12 months, with DTOCs peaking at 5.67% (in November 2016). During the site visit the trust described its approach to planning discharge, transfer and transition to improve this position, including reviewing good practice in a neighbouring trust, creation of an integrated discharge hub, working with the Local Authority and local community services provider, and improved internal processes to ensure senior managers are made of aware of the daily bed availability and potential discharges by 10am every day. The trust described innovative work to provide the Trusted Assessor role using therapists and registered nurses via a registered training programme, which enables staff to refer patients for simple packages of care. The trust acknowledged the need to embed this work further and to engage a wider group of staff to support more patients to return home faster.  The SAFER patient care bundle (a tool to reduce delays to patients in inpatient wards) needs to be embedded and spread over a wider range of services in the trust, although it reports that staff engagement is good. This is supported by the trust’s staff survey engagement results for 2016 where it benchmarked above average for overall staff engagement.  The trust is working with an external clinical productivity specialist company to improve its theatre productivity.  The benefit of using the ‘Getting It Right First Time’ (GIRFT) programme has been limited because only 9% of the trust’s activity is elective and, to date, the most advanced GIRFT programme is in elective trauma and orthopaedics, which the trust does not provide. The trust did describe some learning from the programme across its fractured neck of femur pathway leading to a reduction in the readmission rate for flap reconstruction which the trust has already implemented. It was acknowledged that there will be more opportunities to improve when further national GIRFT data is released, to develop this work in other areas.

How effectively is the trust using its workforce to maximise patient benefit and provide high quality care?

 The trust was within its agency staff ceiling in 2016/17 and believes it will be within its ceiling again in 2017/18. However, the trust has recently undertaken a review of the nursing establishment, resulting in an increase in supervisory time for some band 7 / ward manager staff, which has led to an increase in the use of temporary staff whilst recruitment plans are implemented.  Staff retention rates are above (better than) the national median, and currently around 87% (August 2017). The trust has a non-executive chaired ‘Workforce and Organisational Development committee’ which reports directly to the Board as the trust actively recognises the importance of its staff to the service it delivers. The Board sees a monthly integrated quality, performance and workforce report. Following the appointment of a new HR director, the trust is reviewing its workforce and a people strategy is being developed to increase focus on improving overall staff experience. An HR business partner has also been seconded to focus on actions relating to staff recruitment and retention. There is a strong focus on understanding the reasons for people leaving the trust, and the organisation makes firm job offers and additional development opportunities to student nurses early on in the training pathway to increase the likelihood they will join and remain in the trust’s employment.  Total pay cost per WAU is lower than the national median although the trust is in the upper (worst) quartile for medical and AHP costs per WAU. While the trust does appear to have opportunities for improvement, particularly in relation to the productivity of doctors and AHPs, this needs to be considered in a multi-disciplinary context. One example given by the Trust was where Physiotherapists have been recruited at higher bands in the Musculo-Skeletal pathway to allow a reduction in the number of middle grade doctors and create a more efficient workforce overall.  The trust has a weekly vacancy review panel which has executive-level sign off, and temporary medical staffing costs are routinely reviewed to assess rates paid and vacancies covered.  At 3.48% in June 2017, the trust is better than the median for average staff sickness rates when

20171123 Poole Hospital NHS FT Use of resources October 2017 3 benchmarked nationally against all acute trusts.  The trust utilises an electronic rostering system and reports using this to its full capability for the nursing workforce. Compliance with the system ‘rules’ (e.g. use of annual leave, training time etc.) is reported fortnightly. The trust is moving AHP workforce rosters onto this system, but there are currently no plans to do the same for medical staff. Job planning for doctors has been in place for many years, and electronic consultant job planning was updated 12 months ago. The trust is working to ensure all consultant job plans are now fully up to date but they did highlight that this is still an area for improvement and would welcome engagement from the National Medical Workforce Programme.  The trust has fewer student nurses than in previous years, and is working with local universities to improve this.  AHP staff rotate into community and social services and work within teams employed by the local community services provider, as well as being embedded in General Practice and the .  The trust described innovative solutions in relation to its skill mix and is actively considering the skills and knowledge required to deliver a service, moving away from rigid professional boundaries and roles. For example, the trust has included the Band 4, Assistant Practitioner roles into the ward establishments (replacing Band 5 registered nurses). Quality indicators are assessed monthly against the key workforce metrics to ensure it maintains the quality of care. The organisation also offers training and support to staff to become Trusted Assessors, rather than relying on the traditional model, which improves the patient pathway and enhances discharge processes. Additionally, AHPs are rotated through a number of different teams and clinical environments, such as community, social care and primary care.  However, the trust acknowledges that further consideration needs to be given to other alternative staffing approaches, and is working with University to consider such roles as Physicians Associates.

How effectively is the trust using its clinical support services to deliver high quality, sustainable services for patients?  The medicines programme demonstrated excellent understanding of the principles of driving up quality through efficient systems and processes through their Pharmacy Transformation Plan which was commended by the National Pharmacy Programme, and the trust has engaged well on reducing the top 10 medicine costs.  The Pharmacy Transformation Plan has been written in collaboration with other provider partners across Dorset in line with the Dorset Pharmacy Strategy and demonstrates strong collaboration, efficient solutions and innovation such as the procurement of a medicines robot and implementation of e-prescribing,  The trust benchmarks in the lowest (best) quartile for cost per test in Pathology services, and has still pushed itself further by leading the development of a local networked approach across several trusts, which should result in further efficiencies.  Pharmacy staff and medicines cost per WAU is in the lower (better than average) quartile of cost nationally. The trust had delivered 90% of the top 10 medicines savings identified by month 4, which means it benchmarks as median for this delivery. The trust noted its work was hampered by availability of the generic medicines and was continuing to focus on this area.

How effectively is the trust managing its corporate services, procurement, estates and facilities to maximise productivity to the benefit of patients?  The trust’s non-pay cost per WAU is in the lowest (best) quartile nationally.  Finance and HR costs are broadly in line with the national average, with finance costs just below (better) than the national median and HR costs just above (worse than) the national average.  The trust described its processes in relation to clinical procurement and has an identified clinician supporting the procurement team with this. This has supported the trust to drive down the costs on the things it buys, and the additional clinical focus supports the team to further challenge and reduce costs on drugs and devices. Additionally, a new innovative inventory management system is being implemented to further reduce stock costs across the organisation, the trust has already

20171123 Poole Hospital NHS FT Use of resources October 2017 4 trialled this system, but significant savings will not be seen until full roll out in 2018/19.  On estates and facilities costs, the trust benchmarks below (better than) the average nationally. The trust is part of the South West sustainability group. The trust has reviewed, and then re- tendered or negotiated its laundry and waste contracts in the last year, as well as combining its internal and external cleaning contracts to make further savings. The trust was able to demonstrate its use of national productivity data to reduce costs in this area. However, the trust is just above (worse than) average for building and engineering maintenance cost against the national benchmark.  There have been savings made through joint procurement with the other providers in Dorset, for example in audit services, printed stationery and prepared culture media contracts. The Dorset NHS providers are looking at further opportunities for back office savings over the coming 12 months.

How effectively is the Trust managing its financial resources to deliver high quality, sustainable services for patients?  In 2016/17 the trust reported a surplus of £0.9m against a control total and plan of £0.8m deficit.  The trust has a Control Total of £3.1m deficit in 2017/18, which it is on target to meet.  The trust is focused on delivering its cost improvement plan (CIP) for 2017/18 despite this being a larger financial value (£10.9m, which is 4.5% of its operating expenditure) than it has delivered in recent years. After the first 5 months of 2016/17 the trust was £0.2m (17%) ahead of its plan and forecasting full delivery for the whole year, however there was still £0.8m of the CIP to be identified. The trust does rely on some non-recurrent and one-off items to deliver this, however this does not appear outside the normal level for other trusts. The trust delivered its CIP programme in full in 2016/17, however 34% of these savings were delivered non-recurrently.  The cash position at the trust is challenging, but the trust has used strong cash management processes to track and manage upcoming issues. This has enabled the trust to avoid the need for extra cash support to fund its activities and meet its financial obligations.  While understanding of costs and what drives them has been improved at the trust in recent years, with the depth of its coding of activity undertaken a specific focus, the trust recognised there is further to go and is continuing to work in this area to ensure it is using its resources as best it can.  The trust uses costing data by division (commonly referred to as service line reporting) to inform decisions. The trust outlined the use of integrated (quality, operations, workforce and finances) performance management to manage its divisions to deliver best use of resources.  The trust demonstrated its focus on commercial income, which included being part of national pilots in areas such as overseas patient income recovery.  The trust limits its use of consultancy spend to areas for which it could not reasonably use or develop in-house expertise or for individual projects which require significant but short term support, for example to support the trust’s input into the Dorset Clinical Services Review implementation.

Outstanding practice

The trust has worked with its Local Authority to implement ‘Trusted Assessor’ role using therapists and registered nurses via a registered training programme, which enables staff to refer patients for simple packages of care. This also links to the trust’s ‘No place like home’ drive which supports patients to be in their own homes wherever possible, which has contributed to the overall downward trend in DToC over the last 12 months

The Pharmacy Transformation Plan has been written in collaboration with other provider partners across Dorset in line with the Dorset Pharmacy Strategy and demonstrates strong collaboration, efficient solutions and innovation such as the procurement of a medicines robot and implementation of e-prescribing

20171123 Poole Hospital NHS FT Use of resources October 2017 5

The Trust’s embedding of clinicians in procurement has supported it to drive significant savings.

The trust has continued to successfully track and manage its cash position and avoid extra cash support, whilst delivering services to meet a flat cash contract.

Areas for improvement

The trust makes uses an e-rostering system for the nursing workforce, but there is further work to do in embedding the benefits of e-rostering across the whole organisation and re-focusing on job planning for doctors to ensure it is fully embedded across all clinical services.

The SAFER patient care bundle needs to be embedded and spread across the organisation and across the full 7-day service.

20171123 Poole Hospital NHS FT Use of resources October 2017 6 Use of Resources report glossary

Term Definition

18-week referral According to this national target, over 92% of patients should wait no longer to treatment than 18 weeks from GP referral to treatment. target

4-hour A&E According to this national target, over 95% of patients should spend four hours target or less in A&E from arrival to transfer, admission or discharge.

Agency spend Over reliance on agency staff can significantly increase costs without increasing productivity. Organisations should aim to reduce the proportion of their pay bill spent on agency staff.

Allied health The term ‘allied health professional’ encompasses practitioners from 12 diverse professional groups, including podiatrists, dietitians, osteopaths, physiotherapists, (AHP) diagnostic radiographers, and speech and language therapists.

AHP cost per This is an AHP specific version of the pay cost per WAU metric. This allows WAU trusts to query why their AHP pay is higher or lower than national peers. Consideration should be given to clinical staff mix and clinical staff skill mix when using this metric.

Biosimilar A biosimilar medicine is a biological medicine which has been shown not to medicine have any clinically meaningful differences from the originator medicine in terms of quality, safety and efficacy.

Cancer 62-day According to this national target, 85% of patients should begin their first wait target definitive treatment for cancer within 62 days following an urgent GP referral for suspected cancer. The target is 90% for NHS cancer screening service referrals.

Capital service This metric assesses the degree to which the organisation’s generated income capacity covers its financing obligations.

Care hours per CHPPD measures the combined number of hours of care provided to a patient patient day over a 24 hour period by both nurses and healthcare support workers. It can be (CHPPD) used to identify unwarranted variation in productivity between wards that have similar speciality, length of stay, layout and patient acuity and dependency.

Cost CIPs are identified schemes to increase efficiency or reduce expenditure. improvement These can include recurrent (year on year) and non-recurrent (one-off) savings. programme CIPs are integral to all trusts’ financial planning and require good, sustained (CIP) performance to be achieved.

Control total Control totals represent the minimum level of financial performance required for the year, against which trust boards, governing bodies and chief executives of trusts are held accountable.

Diagnostic 6- According to this national target, at least 99% of patients should wait no longer week wait target than 6 weeks for a diagnostic procedure.

20171123 Poole Hospital NHS FT Use of resources October 2017 7 Did not attend A high level of DNAs indicates a system that might be making unnecessary (DNA) rate outpatient appointments or failing to communicate clearly with patients. It also might mean the hospital has made appointments at inappropriate times, eg school closing hour. Patients might not be clear how to rearrange an appointment. Lowering this rate would help the trust save costs on unconfirmed appointments and increase system efficiency.

Distance from This metric measures the variance between the trust’s annual financial plan financial plan and its actual performance. Trusts are expected to be on, or ahead, of financial plan, to ensure the sector achieves, or exceeds, its annual forecast. Being behind plan may be the result of poor financial management, poor financial planning or both.

Doctors cost This is a doctor specific version of the pay cost per WAU metric. This allows per WAU trusts to query why their doctor pay is higher or lower than national peers. Consideration should be given to clinical staff mix and clinical staff skill mix when using this metric.

Delayed A DTOC from acute or non-acute care occurs when a patient is ready to depart transfers of care from such care is still occupying a bed. This happens for a number of reasons, (DTOC) such as awaiting completion of assessment, public funding, further non-acute NHS care, residential home placement or availability, or care package in own home, or due to patient or family choice.

EBITDA Earnings Before Interest, Tax, Depreciation and Amortisation divided by total revenue. This is a measurement of an organisation’s operating profitability as a percentage of its total revenue.

Emergency This metric looks at the number of emergency readmissions within 30 days of readmissions the original procedure/stay, and the associated financial opportunity of reducing this number. The percentage of patients readmitted to hospital within 30 days of discharge can be an indicator of the quality of care received during the first admission and how appropriate the original decision made to discharge was.

Electronic staff ESR is an electronic human resources and payroll database system used by record (ESR) the NHS to manage its staff.

Estates cost per This metric examines the overall cost-effectiveness of the trust’s estates, square metre looking at the cost per square metre. The aim is to reduce property costs relative to those paid by peers over time.

Finance cost This metric shows the annual cost of the finance department for each £100 per million of trust turnover. A low value is preferable to a high value but the quality £100 million and efficiency of the department’s services should also be considered. turnover

Getting It Right GIRFT is a national programme designed to improve medical care within the First Time NHS by reducing unwarranted variations. (GIRFT) programme

Human This metric shows the annual cost of the trust’s HR department for each £100 Resources (HR) million of trust turnover. A low value is preferable to a high value but the quality cost per £100 and efficiency of the department’s services should also be considered.

20171123 Poole Hospital NHS FT Use of resources October 2017 8 million turnover

Income and This metric measures the degree to which an organisation is operating at a expenditure surplus or deficit. Operating at a sustained deficit indicates that a provider may (I&E) margin not be financially viable or sustainable.

Key line of KLOEs are high-level questions around which the Use of Resources enquiry (KLOE) assessment framework is based and the lens through which trust performance on Use of Resources should be seen.

Liquidity (days) This metric measures the days of operating costs held in cash or cash equivalent forms. This reflects the provider’s ability to pay staff and suppliers in the immediate term. Providers should maintain a positive number of days of liquidity.

Model Hospital The Model Hospital is a digital tool designed to help NHS providers improve their productivity and efficiency. It gives trusts information on key performance metrics, from board to ward, advises them on the most efficient allocation of resources and allows them to measure performance against one another using data, benchmarks and good practice to identify what good looks like.

Non-pay cost This metric shows the non-staff element of trust cost to produce one WAU across per WAU all areas of clinical activity. A lower than average figure is preferable as it suggests the trust spends less per standardised unit of activity than other trusts. This allows trusts to investigate why their non-pay spend is higher or lower than national peers.

Nurses cost per This is a nurse specific version of the pay cost per WAU metric. This allows WAU trusts to query why their nurse pay is higher or lower than national peers. Consideration should be given to clinical staff mix and clinical staff skill mix when using this metric.

Overall cost per The cost per test is the average cost of undertaking one pathology test across test all disciplines, taking into account all pay and non-pay cost items. Low value is preferable to a high value but the mix of tests across disciplines and the specialist nature of work undertaken should be considered. This should be done by selecting the appropriate peer group (‘Pathology’) on the Model Hospital. Other metrics to consider are discipline level cost per test.

Pay cost per This metric shows the staff element of trust cost to produce one WAU across WAU all areas of clinical activity. A lower than average figure is preferable as it suggests the trust spends less on staff per standardised unit of activity than other trusts. This allows trusts to investigate why their pay is higher or lower than national peers.

Peer group Peer group is defined by the trust’s size according to spend for benchmarking purposes.

Private Finance PFI is a procurement method which uses private sector investment in order to Initiative (PFI) deliver infrastructure and/or services for the public sector.

Patient-level Patient-level costs are calculated by tracing resources actually used by a costs patient and associated costs

Pre-procedure This metric looks at the length of stay between admission and an elective

20171123 Poole Hospital NHS FT Use of resources October 2017 9 elective bed procedure being carried out – the aim being to minimise it – and the associated days financial productivity opportunity of reducing this. Better performers will have a lower number of bed days.

Pre-procedure This metric looks at the length of stay between admission and an emergency non-elective procedure being carried out – the aim being to minimise it – and the associated bed days financial productivity opportunity of reducing this. Better performers will have a lower number of bed days.

Procurement This metric provides an indication of the operational efficiency and price Process performance of the trust’s procurement process. It provides a combined score Efficiency and of 5 individual metrics which assess both engagement with price benchmarking Price (the process element) and the prices secured for the goods purchased Performance compared to other trusts (the performance element). A high score indicates Score that the procurement function of the trust is efficient and is performing well in securing the best prices.

Sickness High levels of staff sickness absence can have a negative impact on absence organisational performance and productivity. Organisations should aim to reduce the number of days lost through sickness absence over time.

Service line SLR brings together the income generated by services and the costs reporting (SLR) associated with providing that service to patients for each operational unit. Management of service lines enables trusts to better understand the combined view of resources, costs and income, and hence profit and loss, by service line or speciality rather than at trust or directorate level.

Supporting Activities that underpin direct clinical care, such as training, medical education, Professional continuing professional development, formal teaching, audit, job planning, Activities (SPA) appraisal, research, clinical management and local clinical governance activities.

Staff retention This metric considers the stability of the workforce. Some turnover in an rate organisation is acceptable and healthy, but a high level can have a negative impact on organisational performance (eg through loss of capacity, skills and knowledge). In most circumstances organisations should seek to reduce the percentage of leavers over time.

Top Ten Top Ten Medicines, linked with the Medicines Value Programme, sets trusts Medicines specific monthly savings targets related to their choice of medicines. This includes the uptake of biosimilar medicines, the use of new generic medicines and choice of product for clinical reasons. These metrics report trusts’ % achievement against these targets. Trusts can assess their success in pursuing these savings (relative to national peers).

Weighted The weighted activity unit is a measure of activity where one WAU is a unit of activity unit hospital activity equivalent to an average elective inpatient stay. (WAU)

20171123 Poole Hospital NHS FT Use of resources October 2017 10