DCHS Operational Plan 2017/18 – 2018/19
Year 2 Refresh
1. Introduction & Strategic Approach
In November 2016, DCHS launched its new clinical strategy, which refreshes its established Integrated Business Plan (IBP) and reflects its position as an established Foundation Trust. This strategy reflects the significant strategic developments that have led to the formulation of the Derbyshire Sustainability and Transformation Partnership (STP) – Joined Up Care Derbyshire, our continued close and effective relationships with our commissioners, partners and stakeholders; and with our staff and service users.
Our strategy is built upon the foundation of high quality clinical care, as reflected in our recent Care Quality Commission (CQC) visit and the recognition of the outstanding level of caring delivered by our workforce. This will help to guide us on our on-going journey; from good to great and to maintain our category 1 status under the new NHSI regime. This Operational Plan details our approach to the delivery of the first 2 years of this strategy and has been written in accordance with NHSI planning guidance and subsequently refreshed at the end of 2017 to reflect the changing context in which DCHS is operating.
Our clinical strategy follows the ‘Triple Aim’, developed by the Institute for Health Improvement (IHI) which will ensure that we work together, as an organisation and with our partners in the Derbyshire Health and Care Community to close the gaps and realise the Triple Aim vision of ‘simultaneously improving the health of the population, enhancing the experience and outcomes of the patient, and reducing the per capita cost of care for the benefit of communities. To ensure that, our plan will deliver:
• High quality services that our communities require now, defined around their needs and what is important to them. • Improvements to the health of our population and the resilience of our communities for the future. • A sustainable health and care system where our resources are used efficiently and responsibly, making the best use of the Derbyshire £
The financial climate within which the contract settlements, that underpin this plan, have been agreed has proved to be extremely challenging and this is reflected in section 6.3. This requires the Trust to deliver a stretched control total surplus of £4.1 million, and an efficiency programme of £13.5million (7%). This is well in excess of previous performance, and brings additional risk to the delivery of the financial plan
The delivery of our plan will therefore continue to require strong leadership to ensure that we are confident in our aspirations and create coherence across the organisation and wider system. We will need to work effectively with our partners in a shared environment to co- create solutions and manage out conflict whilst leading with courage and conviction. As such
1 we understand the challenge ahead is great; but if effectively delivered the opportunities to transform care for the people of Derbyshire will more than justify the effort. To successfully address these challenges we will need to develop our leaders and our leadership behaviours; building upon the DCHS Way and the organisational models that underpin this.
DCHS has made strong progress in the delivery of year one of our two year plan, working as a system leader transforming how we deliver care for the people of Derbyshire and delivering improved clinical outcomes in areas such as in wound management, through new and innovative approaches to care
In December 2017 the DCHS Board undertook a refresh of the Trust’s strategic priorities. The refresh addresses issues raised by Board members and builds upon the existing strategic priorities and combines them into key themes. The refresh of the operational plan for 2018/19 has been undertaken in light of these new strategic priorities shown below
• To embed a culture and practice of continuous service improvement across all areas of the Trust • Recognising that we are entering a period of change, build upon our success of attracting, retaining, empowering people and developing leadership to embrace a culture of high support, strong performance and quality improvement • Ensure that we continuously look for opportunities to improve value for money through innovation, transformation and elimination of unwarranted variation • Take a leadership role in the Derbyshire health and social care system working with partners to maximise the system’s contribution to improving the experience of care, improving the health of the population, and reducing the per capita cost of care
2. Strategic and Planning Context
The final version of the Derbyshire STP was submitted on the 21st October 2016. The STP recognises the financial Challenges across the Derbyshire Health and Care system and is now being progressed through a number of key work streams:
Place based Learning Maternity Children Urgent Care Care Disability
Mental Access to Cancer and Prevention Health Primary Care Planned Care
This plan places significant emphasis on place based care and DCHS will work with its partners to develop the necessary services based on the investment available, which is reflected in section 4.3 below. We recognise that in delivering place based services our actions need to be universal, to address inequalities and improve outcomes, and to be delivered at a scale and with an intensity that is proportionate to the level of need.
DCHS has, and continues to take a strong system leadership role in the development and delivery of the strategic objectives of our STP, “Joined Up Care Derbyshire”. As part of this DCHS has, during 2017/18, shaped and delivered major transformations which enable the delivery of care closer to home and the further development and efficient utilisation of the Derbyshire public estate.
2.1 Better Care Closer to Home
We know that people do better mentally and physically if they can be cared for close to home by health and care staff based in the community. North Derbyshire and Hardwick Clinical Commissioning Groups concluded the ‘Better Care Closer to Home’ consultation at the end of June 2016. The proposals represent a collaborative approach to transforming care at a system level so that people can be supported in their own homes and communities more effectively. DCHS is working with other healthcare providers such as General 2
Practice and Mental Health services to help implement the agreed outcomes. During 2017/18 DCHS has made significant progress in implementing the recommendations of the consultation, developing our integrated community teams and supporting the development of the dementia rapid response team that support care for people in their own homes and therefore reducing the need for community hospital beds for rehabilitation and enabling us to reconfigure our day hospital services to better meet the needs of our patients and those that care for them.
A period of public engagement, ‘Joined up care in Belper’ led by South Derbyshire CCG, around changes to the way local services are provided for patients concluded on 30th March 2018 and A full report regarding the outcome from this is awaited. The proposed changes will shape where care is delivered in the south of the county and is aligned with the overarching principles of the Derbyshire STP and the DCHS Clinical Strategy, by ensuring that, ‘wherever clinically suitable, care should be provided as close to the place a patient calls home as possible’. Actions to deliver these transformation changes will be managed within the DCHS operational plans in accordance with the overarching project plans.
It is anticipated that this engagement also form part of a wider, commissioner led, county review of bed based care in the south of the county.
2.2 Erewash Vanguard
DCHS continues to work with partners in Erewash to further develop the Vanguard Multispecialty Community Provider (MCP) model. All partners have committed to an Alliance contract to deliver the best outcomes for the people of Erewash and deliver care in a seamless way. The development of On-day services, for those patients who require an urgent appointment or same day access, will be a key priority within the vanguard and DCHS will continue to develop these throughout 2018 and 2019.
2.3 Urgent Care
During 2018/19 DCHS will work in collaboration with commissioners and partners to deliver a fully integrated 24/7 365 urgent care service in line with the requirements of the national specification. A whole system strategy is being developed to refreshing urgent care in Derbyshire to ensure we use our collective assets for the good of our shared population. For DCHS this will include a review of the services currently provided at the 4 Minor Injury Units along with urgent care, supporting general practice colleagues through community services as well as in the service offer provided from the 3 DCHS General Practices
2.4 Musculoskeletal Triage
DCHS will work with commissioners and acute provider colleagues to implement the mandated MSK triage service in the north and south of the county. It is anticipated that this will result in DHCS operating as lead provider for this service.
3. Improving the health of the population
3.1 Public Health Organisation
Prevention and Wellbeing are at the heart of the STP and DCHS is strongly committed to the delivery of a public health approach throughout the organisation. We have the potential to impact positively on the health and wellbeing of each person every time that we come into contact with them. If we do this well it will positively improve the health of our population in the future to help us reduce avoidable demand and to meet demand more appropriately. Because the most effective way to spend public money is on preventing ill health or on identifying illness early, we want to ensure that all opportunities are taken by adopting a systematic population-based approach to improving health which will include our work to support the development of Local Authority Wellness Hubs, within the context of the STP. This will be a new way of working for many of us, through which we will pursue the objectives detailed in Table 1
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Table 1 Public Health Actions Areas Continue to educate staff about maximising the use of finite commissioning resources and encourage Healthcare conscious decision making from the ground up for best use of resources. public health Delivery of clinical and cost effective care by reviewing and applying evidence based pathways of care and minimising variation in service delivery Improving the Continue with the on-going development of a preventative approach to care, educating the wider wider workforce on what the wider determinants of public health are, the impact these can have on determinants population health, and how adopting a coaching and behaviour change approach across the of health organisation can improve outcomes for patients and address health inequalities Promote ‘brief intervention’ approaches ensuring staff are confident to take a holistic approach when discussing with the patient their health needs Health Continue to further develop staff wellbeing initiatives and support based on the findings of the 16/17 Improvement staff health needs assessment with specific actions to around caring responsibilities and financial pressures as well as working to improve physical health by working in partnership with teams in Occupational Health and Physiotherapy. Continue to improve the vaccination and immunisation uptake rates for all school age immunisations and for staff flu vaccination rates Health Continue to review the Trust Emergency Preparedness plan to ensure that DCHS is able to respond protection with service and system resilience when required Ensure future flu campaigns meet the needs of our increasingly agile workforce
3.2 Supporting Research, Innovation and Growth
The DCHS Research and Innovation Group will ensure that evidence based practice is used to support services to deliver improved outcomes for their patients. We will continue to develop our research expertise in front line services and to participate, where appropriate, with research projects relevant to our service delivery. We will develop strategic partnerships with research networks, universities and other NHS providers to increase our research credibility and to ensure we are better positioned to undertake research studies generated nationally by academic or commercial organisations and by our own staff. We will engage our service users so that they can choose to be part of the development of the evidence base and have access to the latest emerging treatment. Through these steps DCHS will contribute to the development of clinically effective practice.
4. Improving the experience of care - Quality and Satisfaction
4.1 Approach to Quality Governance
4.1.1 Named Executive Lead
Executive leadership is provided by Carolyn White, Chief Nurse and Director of Quality, in partnership with Rick Meredith, Medical Director
4.1.2 From Good to Great – Our approach to achieving our ambition.
As a trust we are committed to our journey from ‘good to great’ and it is with this in mind that we will continue to build on the positive feedback we have had from independent regulators over the last few years. DCHS has developed a comprehensive quality improvement and assurance framework over the last four years which has facilitated year on year improvements in the quality of our services and the underpinning governance arrangements. We have used this framework to improve the quality of those services which were rated as requiring improvement in our last CQC inspection and are confident now, that through rigorous compliance assessment, services have addressed any deficits identified as part of the inspection process.
Quality improvement is central to all that we do, with our patients being at the centre of all of our decisions. We have a number of initiatives driving quality improvements including Caring Always – our promises to patients, Quality Always – our clinical assessment and accreditation programme and Outstanding Way – which is facilitating front line staff to ensure that our working practices are as efficient and effective as possible, driving out repetition and actions that add no value to patient care.
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Central to our quality plans is a desire to ensure that care is personalised for our patients and that our focus is based on ‘What Matters to You?’. In this way we believe that high quality person centred care will be consistently offered to our patients and that we will ensure that our staff are able to deliver services that meet the standards defined in the NHS Constitution and by the CQC.
4.1.3 Patient Safety
DCHS is actively engaged with the national ‘Sign Up To Safety’ Campaign. We remain committed to the reduction of harm to patients through the continued delivery of high quality care and to ensure that 95% of patients receive care with no avoidable harm. To deliver this we will continue to implement our targeted reduction strategies. Our focus in the coming year will be related to the management of chronic wounds including pressure ulcers, leg ulcers, non-healing surgical wounds and diabetic foot complications; improving our management of medical equipment across the trust; a focus on medicines management safety including reduction in the reliance on patient group directions and on ensuring that we get the best value out of medicines and pharmacy, as well as training our staff in human factors and systems thinking. Where serious harm does occur we will ensure that the Duty of Candour is exercised and that patients or their advocates are informed of any lessons learned.
We will also work to review our safeguarding arrangements in response to the increasing safeguarding agenda for adults and children. It is clear that this must promote not just reactive safeguarding approaches but also responsive and proactive measures, ensuring DCHS remains complaint with national legislation.
4.1.4 Measures being used to demonstrate and evidence the impact of investment in quality improvement
Our Quality Always programme is led by the Chief Nurse and overseen by a programme management approach. Key performance indicators for the programme have been developed and are reviewed regularly. In addition the programme is supported by our research team who are undertaking its formal evaluation and the benefits this has realised.
In addition the trust has developed an interactive real time clinical dashboard for clinical managers to assess and monitor their own performance and compare and contrast this with similar trust services.
Our clinical effectiveness team are working on a series of patient outcome measures which will enable us to better evidence the impact of care plans and practice on specific patient groups and we expect these to start to report early in 2018 and to be developed and rolled out throughout 2019.
4.2 Quality Improvement Plan Table 2 Initiative Quality Improvement Plans National clinical The trust participates in those national audits relevant to our services which currently include: audits sentinel stroke, national diabetes audits (including foot care and core), learning disability mortality, Parkinson’s Audit, and Serious Hazards of Transfusion The 4 priority DCHS, alongside our partners, will continue to support the delivery of seven day hospital standards for seven- services. During 2018/19 DCHS will work to increase therapy input over 6 days, within our day hospital services existing resources, to help patients to receive more timely interventions, improve clinical outcomes as well as reducing length of stay and delays in transfers of care. Where patients are admitted to DCHS wards, as either step up from home or step down from an acute admission all patients are reviewed and assessed by an appropriate senior clinician. Where an inpatient may require access to diagnostics that are not available within the community facility, or where it is deemed that access to consultant-directed intervention is required agreed clinical protocols have been developed to ensure patients are transferred in a timely manner to an appropriate facility. Patients within rehabilitation and urgent care wards are reviewed daily providing timely and directed therapy and interventions to support timely and appropriate discharge. We will work with our colleagues within Derbyshire to ensure our Meeting the strategic needs of the Derbyshire STP to develop resilient workforce plans that support equitable provision across seven days. 5
Safe staffing DCHS will be reviewing its safe staffing requirements in line with STP place based care proposals going forwards. We are currently working with the Carter team to review community staffing and will continue to support and inform this work through 2018/19 Improving the quality We have published our learning from deaths policy and have established a mortality review of mortality review group which oversees mortality review in DCHS. We have a robust process for conducting and Serious Incident case note reviews and more comprehensive investigations into deaths “in scope” as outlined Investigation and in our learning from deaths policy with Mortality Reports published at Trust Board meetings. All unexpected deaths are peer reviewed and all serious incidents undergo root cause subsequent learning analysis Going forward, we will work with other community provider trusts and the regulators and action to agree a consistent case note review tool as currently obtains in Acute Trusts. We will continue to embed our processes for cascading learning from death review processes across the Trust. Anti-microbial All inpatient antimicrobial prescribing is audited and reported through our infection prevention resistance and control group. Infection prevention DCHS has a strong track record for good infection prevention and control. We will continue to and control monitor this through regular IPC audit Falls Our falls working group will continue to work towards reducing falls in hospital and in patients own homes and have set clear objectives to achieve this. We will continue to have a specific focus on reducing falls in older people with mental health conditions Sepsis Sepsis education forms a key part of our staff training programme as part of our recognising the deteriorating patient. This will continue to be delivered and its impact monitored Pressure ulcers Pressure ulcers remain our single greatest challenge. We will continue to work with health partners and drive improvements through and DCHS have set an ambitious 20% reduction target this year which will be achieved through greater focus on: • Exploiting technological support solutions • Improved clinical care through greater staff awareness and training • Patient/carer engagement • Using a health coaching and motivational interview approach to work with our patients to deliver the outcomes important to them • Assessment of the incidence of pressure ulcers and the relationship with deprivation • Review of the clinical pathway against the evidence base End of Life Care We have approved our End of Life Care strategy and will be working develop a strategy implementation plan which covers the translation of the strategy into implications at divisional level, the workforce implications of delivering the strategy and a read across to other key enablers such as training requirements, the IT infrastructure to support the delivery of the strategy, Quality Improvement as well as contextualising the strategy and its delivery within the wider Derbyshire STP. Patient experience We will continue to engage with and learn from our patients and carers through our network of patient engagement. As we work to deliver more services in and close to home we recognise the importance of the development of social capital and person centred goals in improving the experience of care and wellbeing and avoiding social isolation. Our commitment to driving improvements is reflected in our complaints management process, by improving the timeliness and quality of our responses and ensuring that we share and act on our learning. National CQUINS Through the implementation of our operational plan we will endeavour deliver our CQUIN targets across the following key areas: Improving Staff Health and Wellbeing, Supporting proactive and safe discharge, Preventing ill health by high risk behaviour e.g. in relation to alcohol and tobacco, Improving assessment of wounds and Personalised care and support planning. DCHS is currently reviewing opportunities in relation to changes to CQUINS which includes the development of a local CQUIN in place of the nationally suspended Proactive and Safe Discharge CQUIN. Winter Planning DCHS continues to take a proactive approach to system-wide winter planning. As part of this the Trust continues to maintain use of flexible capacity around our pathway 3 community hospital beds. However, to maintain system capacity we need to ensure that there is resilience across all our community services as well as bedded care, as we work with commissioners to deliver their QIPP requirements.
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We will work to ensure that our quality plans and priorities are aligned to those of our partners within the Derbyshire system. We will use our specialist skills and services to support people living in care homes, developing partnership working with colleagues in other organisations and sectors where we can add value as we continue to develop our place based care.
The Trust’s measure of compliance against these standards will be monitored through the Quality Schedule which will be reported to the Quality and Performance group of the STP
4.2.1 Quality Improvement
DCHS is committed to embedding a coherent Quality Improvement methodology across the Trust. We will build upon the Health Coaching approach ‘A time to heal’ developed during 2017/18. During 2018, DCHS will adopt a single, easy-to-understand and visible Quality Improvement (QI) methodology. It is proposed that the Institute of Healthcare Improvement QI approach will be the basis of the methodology. Our QI approach will be aligned with the development of our Leadership Strategy and underpinned by the existing frameworks (DCHS Way, Big 9, and Quality Always), strategies (clinical and corporate) and the Operational Plan.
Our ambition is to build upon the foundation of the DCHS Way Infrastructure (Quality Service, Quality People, Quality Business) in delivering quality improvement and continuous learning across all areas of the Trust, both clinical and non-clinical. This will be delivered through a social movement approach around QI in all divisions and amongst all teams in keeping with our stated value “that everyone’s contribution matters”. The DCHS Clinical Strategy and IHI Triple Aim are our anchor points, pulling together the improvement of patient experience, improvement of population health outcomes and reduction in the per capita cost of healthcare.
4.2.2 Quality Planning – creation, assessment, governance and monitoring
The Trust has recently enhanced our Quality Impact Assessment (QIA) and governance processes for all transactional and transformational change processes. The new QIA documentation has been developed in collaboration with system colleagues to provide transparency and assurance around the impact of changes.
Schemes for service and cost improvements are developed at an operational level and assessed for feasibility by the Executive led Plan Delivery Group Each project plan includes a quality impact assessment (QIA), equality impact assessment, risk assessment and financial profile. Schemes deemed viable by the Plan Delivery Group are independently assessed for its potential impact on quality by a panel consisting of the Chief Nurse, Medical Director and a Non-executive Director. The process is facilitated by the Programme Management Office which also provides progress reports to the Plan Delivery Group and Quality Business Committee of the Board. Our Governance process was developed using Birmingham Children’s hospital framework illustrated as best practice in the NQB Quality Impact Assess provider Cost Improvement plan Guidance 2013. The process can be summarised as follows:
Initiate Plan Implement Review
•Feasibility agreed •QIA signed off •Delivery against key •Benefits and •Benefits identified •Project plan and milestones quality review at 6 risk assessment •Management of risks months signed off •Tracking of KPIs •Confirmation of plans for future reviews
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All transactional and transformation changes that determine the Trust’s Sustainable Quality Improvement Plans (SQIP) are assessed for feasibility through a quality impact assessment (QIA), equality impact assessment, risk assessment and financial profile. Schemes deemed viable by the Plan Delivery Group are
7 independently assessed for their potential impact on quality by a panel consisting of the Chief Nurse, Medical Director and a Non-executive Director.
DCHS are equally keen to ensure that Quality Impact is fully considered and understood in relation to the commissioners QIPP proposals. To date, the QIPP schemes identified by commissioners have not contained the detail required to enable DCHS to undertake a fully comprehensive Quality Impact Assessment and none have been provided by commissioners. As a result the proposed schemes cannot be supported from a clinical and patient quality perspective. DCHS will however continue to work with clinical colleagues across the system to explore opportunities and schemes that can deliver system efficiencies as well as providing sustainable, resilient and safe care for patients. These schemes will be based upon evidence based new models of care around the country, recognising the necessity to respond to a more integrated model of care.
4.2.2 Triangulation of quality with workforce and finance
The Board receives an integrated performance dashboard on a monthly basis which includes staffing, quality and financial metrics. In addition all clinical managers have access to a live interactive clinical dashboard which details key performance indicators for quality and staffing
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4.3 This section outlines the operational plans which are intended to ensure that our services remain sustainable whilst meeting the objectives laid out within the NHS Mandate and the Planning “Must Dos”. These plans are aligned with those of our partners and will support the effective implementation of the business cases within the STP and the effective transformation of care within Derbyshire, where resources allow. The themes reflected below will be supported by detailed operational delivery plans and clear reporting mechanisms (see appendix one) to provide assurance to our Board and its sub committees that we maintain an effective grip on delivery, timing and budget and that through this we will mitigate our Board Assurance Framework risks outlined in Appendix 2
Service Areas: ICS – Integrated Community Services, PC – Planned Care, HW&I – Heath, Wellbeing & Inclusion
STP Objectives: P – Place, Pr – Prevention & Self Management, UC – Urgent Care, SE – System Efficiency, SM – System Management, HS – Appropriate & effective treatment at hospital sites, LD – Learning Disability, C&M – Children’s & Maternity, MH – Mental Health, PC - Planned Care, SC – Specialist Community Service
Table 3 Ref Service Service Development Priorities STP Area Objective 1 All • Work to improve the efficiency and experience of the patient journey for both patients and referrers. P, PC, Pr • Engage our partners to ensure that we support the development of evidence based care pathways and to deliver proactive approaches to care to improve the management of long term conditions e.g. diabetes, dysphagia and musculoskeletal and to monitor their efficacy. • Identify patients who are scheduled for outpatient or primary care follow-up and would benefit from personalised care and support 2 All • Continue to focus on the prevention agenda, maximising health gains and avoiding unnecessary health care costs. Pr & P • Engage our patients to understand their needs and requirements and to increase their knowledge, skills and confidence to manage their health and wellbeing. • Embed this approach within all services supported by a coaching and behaviour change approach and the support of our Health Psychology service 3 All • Develop specific services to meet the needs of specific place population, P • Respond to feedback from clients and service users when developing and improving our services, such as ensuring our services are available at different times and days (including out of hours, evening sessions and some Saturday mornings) and are delivered in local community venues with an emphasis on delivery in the most deprived areas 4 All • Develop our medicines management function to support the reduction in antibiotic consumption. We will continue to develop our non-medical SE prescribing initiatives and develop robust and appropriate governance arrangements to support this. 5 All • Review the locations of clinical activity and services to ensure the maximised use of, and maximum value from, our estate and assets and to C&M & SE facilitate effective integrated working with our voluntary sector and social care partners 6 All • Maximise the exploitation of our electronic clinical system and equipment to ensure efficient co-ordination and provision of care and to improve Pr & SE the monitoring of patients • Utilise shared electronic records opportunities to support integrated care at home and promote maintenance of independence in Place 7 All • Use our business intelligence systems to support the reduction of unwarranted variation across clinical and corporate services to reduce SE duplication and inefficiency and embed a standardised approach to the delivery of care that optimises clinical quality, efficiency and productivity and supports the delivery of our public health action plan in relation to Healthcare Public Health. • To reduce the delayed transfers of care and meet our target of 3.5% 8 ICS & • Support the appropriate use of personal budgets and personal health budgets to support person centred care and engagement to deliver Pr PC individual packages of care in the most effective and efficient way. 9
9 HW&I & • Maximise the efficiency of General Practice and Integrated community teams to support proposed inpatient rationalisation and to work P ICS collaboratively with other agencies in Place to provide quality person centred care • Develop consistent seven day services, where appropriate and in collaboration with partners. Particular areas of focus include the development of the discharge to assess services, access to same day GP appointments, the development of Personalised Care and Support Planning , delivery of the DCHS End of Life and Frailty Strategies 10 HWBI & • Developing services to support the pillars of frailty P ICS • Acting on and embedding the frailty contract within our practices 11 ICS • Reduce the numbers of older people with dementia being admitted into an acute mental health bed for assessment/treatment by providing this HS, MH & in an appropriate community setting via a specialist community multi-disciplinary team (Dementia Rapid Response Team - DRRT) and through P the early recognition and treatment of delirium 12 ICS • With partners in health, care and the voluntary sector develop Older People’s Mental Health services, as part of a community facing, enhanced Pr, HS, P & organic pathway to improve the experience and outcomes for people with dementia, and their carers. MH 13 ICS • Develop a Unified Community Learning Disability model to promote new approaches to care and support pathways; including the development LD & SE of more personalised, efficient and effective short break respite services. • Develop our staffing model and workforce consistency to support the future Place based community model 14 ICS • Develop our emergency and urgent care services to ensure patients are seen by the most appropriate person, at the right place at the right P & HS time. We will work with our partners to maximise the use and effectiveness of our urgent care services 15 PC • Progress the review of the portfolio of services with partner providers to ensure that the community provision meets the health needs of the P, PC & HS population in a locally accessible and sustainable way 16 PC • Respond to commissioner’s decision to retender the wheelchair service, whilst striving to maintain service continuity. SC 17 PC • Review of our catering facilities to ensure that we provide a quality, nutritionally balanced and freshly cooked menu for patients, visitors and Pr staff; and respond to patient feedback. 18 PC • Develop a county wide single point of access and local triage to enable easy access for all agencies P & LD 19 HW&I • Improve health literacy and sexual health awareness of the target populations by offering and increasing the uptake of testing, by focusing on Pr increasing accessibility such as testing at home and developing walk-in services 20 HW&I • Improve access initially by ensuring all practices are signed up to the Extended Hours Directed Enhanced Services and support the delivery of P & SE the GP5YFV. Increase the use of online and telephone management and review the process for streaming patient demand. • Develop a shared infrastructure between our own practices, including reviewing opportunities to develop new roles and using existing roles innovatively to improve efficiency and quality for all patients 21 HW&I • Respond to feedback from clients, in particular from children and young adults themselves on how we are able to ensure our services are C&M accessible, responsive, welcoming and inclusive to all. • Work with our schools to help children and young people to make healthy life choices and to develop their emotional resilience and wellbeing. 22 HW&I • Work with our county and city commissioners to continue to promote and improve the health of the population, including the reduction of C&M childhood obesity and the continued improvement in breastfeeding sustainment rates
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5.4 Workforce
5.4.1 Workforce Strategy
DCHS recognises the significant risks surrounding future workforce requirements for the delivery of its plans and in response to this we have worked with each Division, our staff forums and the Workforce planning groups to refresh our Workforce strategy; ensuring this is aligned to the clinical and STP strategies across Derbyshire. The Trust will also refresh the People Strategy which will be developed with three core domains; Attract, Develop and Retain, and two underpinning themes Leadership and Inclusion.
Through the implementation of our People Strategy we will provide a flexible employment offer that meets the needs of staff at each stage of their career. This will also embed our principle of being an employer of choice with a strong employment brand and market position. Through our leadership strategy we will ensure that our managers have the right management and leadership skills and competencies to work in the future landscape . The implementation of this strategy and the wider STP will require strong leadership to ensure that we are confident in our aspirations; create coherence across the organisations and wider system; work effectively with partners to co-create solutions and manage out conflict whilst leading with courage and conviction. Leaders will need support and development to help them rise to this challenge and this will need to be underpinned by effective communications and change management. To deliver this effectively we will also need to ensure the appropriate change management capacity is available.
We recognise the important contribution that the voluntary and community sector make in the delivery of care and the promotion of social value and the development of a sustainable workforce. We will continue to work with our partners in these areas, recognising their contribution to developing a sustainable workforce, developing services in partnership with them and working to explore new opportunities for them to make a difference to the wellbeing of our patients as we develop our volunteer strategy.
In addition we will continue to work with our partners through the Talent Academy; working to explore new opportunities for joint working and developing services in partnership with them to support the development of a sustainable workforce.
The move to care closer to home and earlier discharge from acute settings means that there is a need for further skill development in the community setting ensuring equitable provision across a seven day period.
5.4.2 Workforce Planning
We have a cyclical, robust, internal workforce planning methodology which triangulates service, finance and workforce requirements. We have led workforce modelling activity across Derbyshire, using the Strategic workforce and education planning (SWiPE) approach, This work will continue as we develop our workforce to meet future service and business requirements.
We will continue to develop our workforce planning and development approach to understanding our workforce, building on the SWIPE methodology to gain a full understanding of our future workforce requirements across both health and social care at “place based” level across Derbyshire. This will allow alignment between health needs at “Place” level and the capacity/capability of the workforce delivering services. In-addition we will use the evidence from our existing workforce modelling to inform our workforce future education and training requirements.
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Our workforce plan for 18/19 will focus on the following themes:
• Sustain – Reducing vacancies, retraining and redeployment of BCCTH staff, bank and responsive increase, internal transfer scheme, rotations, careers advice and retaining future retirees • Optimise – Workforce planning and skills mix (Norfolk, Bravo and Swipe), competency framework, maximising attendance and rostering • Transform – Grow our own (ACP, Nurse Associates, Practitioners and Apprentices), multi- generational offer and retaining staff
The development of integrated services and new models of care delivery will require the development of new workforce models in which DCHS staff work across acute, community and primary care settings. Our current workforce plans have specifically identified that we need to continue our efforts in the following areas:
• Workforce consistency; including Multidisciplinary roles and teams • Developing the skills and competencies of the current workforce to provide care to a different cohort of patients across a range of settings. • Expansion of the skills and competences of existing clinical support staff across bands 1-4. • Increased capacity amongst advanced practitioners at bands 6/7and 8A through year on year growth in ACP trainee posts. • Development of minor illness expertise in line with the requirements of the Derbyshire Urgent Care Strategy • Further embed the Health Coaching approach to support behaviour change, and expand the public health knowledge and skills of our workforce to ensure we help the people we serve to stay healthier for longer. • Improving resilience in relation to General Practice workforce, through the use of ANPs and Pharmacists, wider roles for GPs along with exploring opportunities around back office functions and cross cover as well as linking in with the federations in Hardwick and Amber Valley • Further skill development in key areas such as public health, end of life care, management of minor mental health issues, long term conditions, patients of a higher dependency and acuity in the community setting where there is equitable provision across a seven day period. . • Mandatory training will be reviewed to ensure that we meet statutory requirements and that where possible a blended approach to training will be adopted to promote the maximum flexibility in terms of access to our staff • Continue to work with our local programmes of transformational change, notably Erewash Multispecialty Community Provider (MCP), Joined Up Care and Better Care Closer to Home and continue the workforce modelling associated with these strategic projects. • Further development of our staff wellbeing service, providing targeted support and engagement in high absence teams as well as for key times in an employee’s life • Improving the quality of incident investigations and to prevent recurrence
Following the analysis of the 2017 National Staff Survey results, and based on consultation, engagement and focused work with staff, a number of areas for development over the coming year have been identified that include: • The role of managers in supporting, developing and leading their teams • Communication across the organisation at all levels • The culture of working extra hours and the impact on health and wellbeing • Access and funding of training and development • Autonomy of staff to make decisions and develop their service, roles and themselves
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5.4.3 Workforce Efficiency Historically we have a strong track record of reducing our use of agency and locum spend though we continue to be set challenging targets. As such we are developing further innovative responses and are engaged in regional work to address “under price cap” arrangements. We continually review our actions with the Trust Board to seek every opportunity to address our position and we are very active in the Derbyshire health economy in relation to increasing the responsiveness, and efficiency of the combined Derbyshire workforce, for example:
• Chairing the Derbyshire Strategic Workforce Implementation Group • Director lead on the workforce “Back office” efficiency schemes • Active member of the Local Workforce Advisory Board, and Chair of Implementation Group • Hosting initiatives such as the regional Return to Practice post and encouraging its expansion beyond Nursing to Allied Health Professionals.
We generally source all of our workforce from our host community so to date have not entered into any overseas recruitment.
5.5.4 Workforce Transformation & New Models
Within the context of the financially constrained climate we recognise that there will be workforce transformation programmes that will include workforce consistency reviews and potential workforce rationalisation in relation to back office efficiencies and decommissioning of service by the CCGs.
The Trust will undertake an in-depth review of the current capacity and capability of the workforce across all services to ensure sustainable planning for the future. This work will be underpinned by the development of our people strategy and further supported by the workforce plan. The workforce plan will be developed with a framework and structure comprising three key components; Sustain, Optimise and Transform. The result of this work will ensure the trust has the right workforce with the right skills delivering care in the right place, and that it is also able to meet the challenging cost improvement programme.
There will be no increase in the workforce budget in 18/19 and potential workforce rationalisation in relation to back office efficiencies and decommissioning of service by the CCGs. Recruitment to our clinical workforce will however continue to ensure we fill our vacancies as they arise. However, there is an assumption that there may be an increase in agency use to ensure we have the right capacity and the right capabilities whilst we develop the workforce and recruit to the specialist roles that will be required. We do however plan to remain within our agency ceiling by responding to the challenges quickly and efficiently and using our internal bank where possible
Beyond this our workforce plans recognise the STP focus on Place and will support delivery of the emerging care models, where, we will help to create integrated and co-located teams working more efficiently to deliver care across Derbyshire. The new care models described within the STP will require: • New ways of working, such as in the integrated teams which we are already developing with our partners. • New roles, such as the approach we have developed in relation to Advanced Clinical Practitioners and Nursing Associates and our work with care providers to increase applicants into this sector. • Review of our learning and development offer to ensure that this is specific to existing and developing roles, underpinned by a more robust approach to training needs analysis. • Increased support to our staff to enable them to work more flexibly and across different settings • Improving our understanding about current workforce risks and challenges. • Supporting and learning from our partners and developing shared flexible workforce solutions,
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DCHS will continue to offer clinical and non-clinical placements to promote future workforce supply, and we will maximise our offer in areas where we have a workforce challenge, such as Allied Health professionals and the registered Nursing workforce. We will continue to develop our apprenticeship framework to support workforce supply across staff groups. In response to the changing arrangements for bursaries we have put in place schemes to both fast track existing staff to undertake registration as well as opportunities for staff to learn whilst they are also earning through Open University courses. Through our leadership within the STP and work with the Local Workforce Action Board (LWAB) we will align our workforce strategy with the needs of the local health and care system.
5.5.5 Workforce Governance
To ensure the robust governance of our workforce plans we have continued our internal approach to the review of emerging operational needs, the on-going position in relation to workforce supply and demand. This in turn strengthens the assurance we are able to give to the Trust Board, through the Quality People Committee, regarding the delivery of our workforce plans.
5.6 Inclusion and Fairness at DCHS
Working with the Board Equalities Forum DCHS is currently redefining our approach to Inclusion as part of the development of the People Strategy. This will reflect our reframing of ‘inclusion as a strategic enabler’ and the longer term strategic approach to support service and workforce transformation and to manage its impact on our communities. The strategy sets out our journey and aspirations to go above and beyond the legal requirement and become an exemplar of best inclusive practice.
The strategy will be refined to the equality delivery system (EDS2) national performance framework and aligned to the 4 goals in order to embed and demonstrate delivery of equitable outcome for all:
Improved Better health patient outcomes access and for all experience
Empowered, Inclusive engaged and leadership & included Governance staff
We are on an exciting journey with our Inclusion approach. It is clear to us that a truly inclusive culture will not be created through a managerial, transactional approach across the organisation but requires more of a ‘social movement’ approach that generates diverse conversations and connections. This has to be supported by robust and effective mechanisms that measure outcomes, drives the social movement work across our systems and structures, including strengthening inclusive and compassionate leadership.
If we deliver well against the inclusion agenda this will also ensure we meet our aspirations to be a strong public health organisation
Key actions identified to ensure the delivery of the strategy and to support our journey from good to great are detailed in the table below: 14
Table 4 Equality Action Objective • Progress the inclusion agenda as a ‘strategic enabler’ within DCHS by taking an inclusive and assets based approach to secure hearts and minds and the right behaviours. • Building inclusive and compassionate leadership capability and promote role modelling • Inclusion is embedded in the DCHS way: visible (seen/heard/felt) and accountability is seen at all levels in our structures, systems, processes, roles and relationships. Inclusive Culturally competent and knowledgeable staff leadership • and • A compassionate culture with zero tolerance of discrimination, bullying and harassment governance • Vibrant connected staff networks and allies across the Trust • Demonstrating we are meeting our Public Sector Equality Duties (PSED) under the Equality Act 2010 and beyond. This will be met through annual EDS2 grading and publishing our annual workforce and service usage diversity analysis report. • Equality Delivery System (EDS2) will be used as a service and quality improvement and organisational development tool to help us transform our services, workforce and culture. Our aim is to show improvement progression, year on year. • Understanding the diversity of service users accessing our services Address • Evidence that service user data is used to improve service delivery health • Implementation of the Accessible Information Standard, including the BSL Charter. inequalities • Equality Impact Risk Screening and Assessments undertaken for all key decisions to demonstrate evidence based decision-making. • Identify and target practical actions to reduce inequalities in health and healthcare outcomes • Targets to increase diversity of workforce and positive improvement in national workforce standards e.g. Workforce Race Equality Standard, Gender Pay Gap and Workforce Disability Equality Standard. Achieve a • Understanding and action taken to address any negative experiences of under-represented groups diverse from Staff Survey. workforce • Employee Inclusion Network Groups supported, valued and members feel that they are part of and have a vital role to play in the transformation of the Trust. • Staff engagement that is inclusive and fair
6. Reducing the per capita cost of healthcare
6.1.1 Approach to Activity Planning
Activity plans for cost and volume services have been based on demand, determined by reviewing referral rates and trends, current waiting times and service developments. Each service has been directly involved in agreeing activity plans to ensure alignment with capacity and therefore that plans are deliverable. These activity plans have been shared with commissioners for sign off and inclusion in the 18/19 contract. DCHS will also pursue the new local incentive scheme, alongside their CCGs, through which savings from acute excess bed day costs will be reinvested.
DCHS recognise the importance for the Trust to have realistic activity plans which align with commissioners plans delivered through robust demand and capacity modelling. This is essential to ensure there is sound financial and workforce planning, and that there is sufficient capacity to meet demand and ensure achievement of operational standards including A&E waits and Referral to Treatment (RTT).
A coordinated two step approach to activity planning has been taken:
• Original baseline activity plans were based on agreed 2016/17 information and historic activity profiles. Activity plans have been refreshed with specific service leads to reflect forecasting information and the impact of any service developments and any factors which have had a non- recurrent impact. These baseline plans have then been shared with commissioners and compared to their plans to identify and understand any significant variances, to then allow us to agree a common baseline.
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• Growth has then been applied to these baselines. Growth takes into account demographic and activity growth based on a consistent national methodology. This has been applied to Outpatients (First and Follow-up), Non-Electives, Electives (Inpatients and Day Cases) and A&E attendances.
The table below details the high level 18/19 cost and volume activity plans Table 5
2018/19 Activity Plan Service Activity
Accident and Emergency 76,105 National Tariff Diagnostic Treatment Centre 48,409 Diagnostic Imaging 3,619 Community Podiatry 134,997 Physiotherapy 118,592 Local Cost and Podiatric Surgery 15,741 Volume Speech and Language Therapy 20,935 Vasectomy 450 Total 418,848
6.1.2 Achievement of Key Milestones
DCHS have historically performed strongly against operational standards linked to A&E and RTT. Commissioners and DCHS are committed to ensuring achievement of these operational standards continues. Indicative activity plans and block contracts are currently being worked through and agreed to ensure this is achievable. This includes consideration of current performance and capacity, impact of demographic growth using the national Indicative Hospital Activity Model (IHAM), and impact of transformational service changes. The impact of these activity plans will then be reflected in operational delivery plans, taking into account workforce impact and session planning.
6.1.3 Financial Planning
The financial context within which the Trust is operating continues to be extremely challenging with the local commissioner’s financial position deteriorating considerably during 2017/18. There have been a number of challenging discussions regarding the contractual out-turn position in 2017/18 and the affordability of contracts remains a significant issue for commissioners going forward.
Against this context, the level of financial risk taken by each organisation within their plan has grown. For DCHS, we will be required to deliver efficiencies of 3.13% to achieve our revised control total, and a further 3.90% to deliver commissioner QIPP including savings in respect of the Better Care Closer to Home transformation programme. Therefore the key financial challenge in 2018/19 will be delivery of the efficiency plan and supporting the delivery of the system wide transformation. In addition, there is still a commissioning QIPP gap which CCGs are discussing with all providers. This is likely to bring further risk to the DCHS position. Against this context, the financial climate will therefore continue to be difficult in 2018/19.
The Trust has demonstrated its financial resilience during these testing times through continuing to achieve its financial plans and targets and based on the audited accounts has delivered an adjusted surplus of £8.647m in 2017/18. This is the position including the total STF funding received by the Trust of £4.061m. For 2018/19, all providers have been issued with updated control totals. The Trust has been issued with a control total of £4.072 million surplus in 2018/19. Those providers who have previously had a control total surplus when STF funding is excluded, have had their control total for 2018/19 reduced. In addition, the Trust has been notified that it will be eligible to receive an additional £0.624m in STF funding. The Trust is therefore planning for a surplus in line with this revised target supported by full receipt of STF funding in 2018/19 of £2.160m
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Against this context, the Trust has refreshed it’s financial plan for 2018/19 which will deliver an EBITDA margin of £10.1m (5.5%) in 2018/19 and a surplus of £4.072m or 2.25% of turnover. This is in line with the control total set by NHS Improvement.
The plan is dependent on the successful delivery of an efficiency programme of £6.0m in 2018/19 or 3.13% of operating expenditure. In addition, the Trust is required to deliver QIPP savings of 3.90% of operating expenses.
6.1.4 Financial Forecasts and Modelling
The initial plan as presented is based on a number of key planning assumptions:- - The national efficiency requirement has been confirmed at 2.0% for 2018/19. - National costs pressures are assumed at 2.1% in each year which when offset against the 2% efficiency, results in a tariff uplift on 0.1%. - The clinical income assumptions underpinning the plan are aligned to the contract agreed with local commissioners and including the agreed QIPP schemes. The successful delivery of these schemes will be a key risk for the Trust during 2018/19. - Revenue surplus of £4.072m which is in line with the revised control total issued to the Trust. - The Trust is in receipt of Sustainability and Transformation funding of £2.161m which includes the additional £0.624m recently notified to the Trust. - Capital Investment Plans of £6.0m which is in excess of the forecast depreciation levels of £4.0m by £2.0m, the funding gap being met from internally generated resources. - In addition to the routine capital programme, the Trust has been successful in bidding for STP capital funding. The value of the bid was £5.9m with £0.95m being drawn down in 2018/19 via the allocation of new PDC capital.
Table 6 (income and expenditure) details the high level income and expenditure position planned for in 2018-19. The surplus levels represent 2.25% of forecast turnover.
Table 7 (balance sheet projections) details the current balance sheet projections. The initial cash-flow forecast shows that the Trust is planning to increase its cash reserves held from £26.6m at the end of 2017-18 to £29.3m at the end of 2018-19.
Table 6 Table 7
Out-Turn Plan Income and Expenditure Balance Sheet 2017-18 2018-19 £m's £m's
Out-Turn Plan 2017-18 2018-19 Non Current Assets 75.1 80.5 £m's £m's Current Assets 37.0 39.4 Clinical Income 181.8 171.6 Other Income 14.3 10.8 Current Liabilities -15.8 -15.5
Total Income 196.1 182.4 Net Current Assets / Liabilities 21.2 23.9
Operating Expenses ( exc impairments) -183.0 -172.3 Provisions - Non Current 0.0 0.0
EBITDA 13.1 10.1 Deferred Income - Non Current 0.0 0.0 EBITDA - % 6.67% 5.53% Total Assets Employed 96.3 104.4 Depreciation -3.5 -4.0
PDC Dividend Payable -1.8 -2.1 Public Divided Capital 0.9 1.9 Retained Earnings 66.4 70.5 Surplus / ( Deficit) In Year 8.6 4.1 Revaluation Reserve 29.0 32.1 Surplus / ( Deficit) In Year - % 4.36% 2.25% Total Assets Employed 96.3 104.4
The cash-flows associated with the capital programme as currently modelled are in excess of the Trust’s forecast depreciation levels by £2.0m which will be met from internally generated resources. 17
The most significant schemes include the investment into early preparatory work regarding a new health development in the Buxton locality, redevelopment of the Walton site, continued investment in the Trust’s IM&T infrastructure and addressing backlog maintenance issues alongside routine equipment replacement.
Table 8 - Our forecast Use of Resources metric under the Single Oversight Framework is a 1 (lowest risk). It is important to understand the level of financial headroom available within the plan as presented here. In order to reduce the rating to a 2 there would need to be a reduction in margin of £2.3m. A further reduction of £1.4m would reduce the overall rating to a 3.
Table 8
Single Oversight Framework - Use of Resources Metric
Metric Weight Out-Turn 2017-18 Plan 2018-19 Score Rating Score Rating
Capital Service Capacity ( x times ) 20.00% 6.90 1.0 4.90 1.0
Liquidity ( Days) 20.00% 41.7 1.0 50.7 1.0
I&E Margin (%) 20.00% 4.30% 1.0 2.20% 1.0
Distance from plan (%) 20.00% 1.68% 1.0 0.00% 1.0
Agency Expenditure (%) 20.00% -49.20% 1.0 0.00 1.0
Overall Rating 1.0 1.0
The key sensitivities / risks that have been considered and table 9 provides an analysis of the impact each of these would have on the base plan presented here. The individual sensitivities identified erode the Trust’s margin and cash position and would have an impact of the reducing the Trust’s overall Financial Rating of a 2. Clearly this would be the position before the implementation of the Trust’s mitigation plan. This is shown in table 9.
Table 9
2018/19 Sensitivity - Combined Scenario Surplus Cash Rating £000's £000's 2018/19
Trust Base Case Plan 4,072 29,308 1
20% CIP slippage -1,280 -1,280 Loss of Service through tendering -1,239 -1,239
Revised Position 1,554 26,789 2
6.2 Efficiency Savings for 2018/19
The level of efficiencies that the Trust will be required to deliver during 2018/19 has been informed by both the national efficiency target for all providers of 2% plus local cost pressures and the additional transformational efficiencies identified by commissioners. The Commissioner QIPP includes the service and system transformation taking place in north Derbyshire as a result of the Better Care closer to Home programme..
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6.3 Capital Planning
Capital Investment Plan
Our capital plan assumes an investment of £6.0m pa. Following the successful completion and handover of the Heanor Site in February 2018, the major areas for investment during 2018/19 are the redevelopment of the Walton and Belper sites and continued investment in the Trust’s IM&T infrastructure and routine backlog maintenance. . This level of investment is in excess of the forecast annual depreciation of £4.0m. The Trust is not seeking external financing and therefore the balance will be funded from internal cash resources.
During 2018/19 we will also work to update our General Practice facilities with 2 new premises at Creswell and Langwith and a major upgrade at Castle Street in Bolsover.
6.4 Estates Management
In addition to the estates developments identified above we will continue to pursue transactional and transformational efficiencies and work to maximise the utilisation of our sites. We will focus on sites at Alfreton and Long Eaton and realise rent reductions from Newholme Hospital. During 2018/19 we will, along with partners in the Derbyshire system, progress the ‘One public estate’ initiative through the development of an integrated hub in Buxton following the successful completion of the land purchase.
Within Derbyshire estates costs are projected to increase significantly in the coming years. We recognise the inefficiencies in our current estate and have, with our partners, identified a range of opportunities that will be key to delivering our service developments and aspirations as well as delivering improvements in efficiency and utilisation. The table 10 captures the STP estates priorities for DCHS
Table 10 Transactional Schemes Transformational Schemes Revaluation of estate – awaiting outcome Better Care Closer to Home Consultation outcome actions Maximise utilisation of LIFT buildings (St Site utilisation and accommodation Oswalds, Long Eaton and Alfreton) – London Road Community Hospital, Belper, Heanor, Walton & Wheatbridge Rent reductions (NHSPS – Babington and Closer working with DHcFT Newholme)
6.5 System Efficiency
DCHS will take as many opportunities as possible to maximise operational productivity, guided by the Model Hospital portal, and to participate fully in associated programmes. DCHS will also contribute and pay attention to Getting It Right First Time recommendations; participation in networked arrangements for procurement, corporate services and diagnostic services; achieving best practice in clinical and other workforce productivity standards (including maintaining very low agency staff usage); and improving the safety and efficiency of providers’ estate and facilities. DCHS, as part of the wider Derbyshire ICS will also consider how to make best use of the digital and technological systems and innovations available to them.
The Trust has worked throughout 2017 with the team sponsored by Lord Carter and NHS Improvement. A significant amount of data has been collated and submitted, in addition to a sharing of DCHS best practice with other community trusts regarding scheduling. We will be focussing our attention on areas where the Carter metrics and the 10 Point Efficiency Plan indicate that further improvement could be made. Specifically we will be looking at the following areas:
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6.5.1 Agency Rules
DCHS has been identified by the Lord Carter case study as a best practice example for temporary staffing solutions. We have undertaken further work to reduce our Agency spend whilst continuing to make patient safety our absolute priority. This includes:
• Successfully recruiting additional team members to our Responsive Workforce team. • Identifying additional actions to increase the bank fill rate; including enhanced rates and opportunities to implement a weekly payroll • Recruiting additional posts to our bank, especially in workforce groups where we have known challenge, such as around Allied Health Professional recruitment, GP recruitment and ACP recruitment • Large-scale recruitment campaign which aims to not only fill current clinical vacancies but also anticipates where we might need extra staff or where vacancies might arise. • Where ‘hard to fill’ areas have been identified we will explore targeted recruitment incentives to secure a permanent workforce more easily. • Introducing a central daily ‘staffing monitoring’ service within People & Organisational Effectiveness, to find solutions to gaps and is reducing shifts sent to bank/agency. • Scrutinising agency spend line by line to remove any unnecessary expenditure, only permitting use in Clinical services to ensure that patient safety is not compromised • Engaging with our existing Advanced Nurse Practitioner workforce to see who is prepared to work extra hours within our GP practices and also liaising with a framework agency to support ANP work to reduce GP locum spend. • Implementation of an additional senior clinical on-call rota to ensure that clinical judgments relating to staffing can be swiftly made to prevent the need for agency cover
6.5.2 Back Office
DCHS is working collaboratively with its STP partners to identify system wide efficiencies such as those that have been identified in relation to utilities, food and waste management costs. We are also working closely with colleagues at DHcFT and have identified significant efficiencies in relation to closer working across People & Organisational Effectiveness, and potentially Estates to reduce the cost of corporate services and administration.
From April 2018 DCHS will host a new joint venture agreement with Derbyshire Community Healthcare for the joint Provision of People and Organisational Effectiveness Services.
6.5.3 Procurement
The Trust has developed its procurement strategy which applies to all its procurement activity and which commits it to take action on all areas of non-pay expenditure by applying good practice in selection, purchasing, prices, stockholding and usage to achieve value for money and appropriate quality.
In line with the Carter Report, and 10 Point Efficiency Plan we have developed a Procurement Transformation Plan. This sets out the key changes and actions required to improve our performance against the key Carter metrics. In addition, the procurement department are working with clinical services to support the delivery of non-pay efficiencies, as well as working with partner organisations to drive further savings through collaborative procurement.
6.5.4 Reducing unwarranted variation
As part of our approach to delivering the Carter principles; and the 10 point efficiency plan DCHS is committed to reducing unwarranted variation and improving efficiency across all services, ensuring that any variation is planned and understood. Work on our business intelligence system continues to support these developments. Through the Outstanding Way initiative we will continually review the 20 quality, effectiveness and productivity of our community therapy, nursing and specialist service provision across the city and county. This approach will allow us to identify and reduce duplication and inefficiency, whilst embedding a standardised approach to the delivery of care. We will measure the impact of our clinical interventions to ensure that we optimise clinical quality, efficiency and productivity. During 2018/19 the Trust will focus on continuing to embed the Outstanding Way programme, utilising benchmarking information, including reference costs to identify opportunities elsewhere such as within pharmacy and catering delivery models to maximise our productivity and efficiency opportunities.
From April 2018 DCHS will host a new joint venture agreement with Derbyshire Community Healthcare for the joint Provision of People and Organisational Effectiveness Services.
6.5.5 Commercial Developments
We continue to monitor commercial development opportunities in line with our commercial development strategy and work closely with our commissioners in relation to the delivery of these contracts. This will require us to evaluate the future tender arrangements for our contracts and work to further align all these contracts with the key priorities within the STP. We have revised our Business Development Framework and adopted a benefits realisation approach to all commercial investments which is monitored through the Quality Business Committee.
DCHS will continue to assess potential commercial developments and tender opportunities in line with its recently refreshed ANSOF matrix. In addition to the wheelchair service a number of tendering opportunities are anticipated during the forthcoming financial year, including dental, city sexual health and 0-19 county services. We will continue to develop organisational capability and capacity to enable the Trust to respond in a timely and effective way to new tenders and alliances as they arise.
6.5.6 Informatics and Technological Transformation
We will continue to exploit both our existing and new technologies to provide increasingly high quality and efficient care supporting our clinicians to deliver better quality outcomes to the people of Derbyshire. Key areas for development in 2018/19 include
• Realising efficiencies through technological transformation - We will work to identify how new specific IT applications can be used to transform how we support particular groups of patients. We will also provide our service users with the opportunity to access services and their medical records on-line, opening access to services and empowering service users
• Business Intelligence to support Clinical Outcomes - We will work to develop our approach to capturing clinical outcomes, adopting a consistent method to understand where we can make a difference to clinical practice and to support our approach to developing and delivering our population health offer.
• Supporting workforce transformation – The application and exploitation of information including disruptive technologies will be a key enabler to our workforce plans helping us to optimise our staffing structures, supporting operational flow and case load management.
We will focus on sharing information within and beyond DCHS to aid the delivery of effective care. We will continue to refine our electronic clinical systems and processes to help our staff work as efficiently as possible whilst providing them with the information to deliver excellent personalised care. We will work to develop our approach to capturing clinical outcomes, adopting a consistent method to understand where we can make a difference to clinical practice and to support our approach to developing and delivering our population health offer.
We will also provide our service users with the opportunity to access services and their medical records on-line, opening access to services and empowering service users. DCHS is a key member of the Derbyshire Information Delivery Board (DIDB) which has agreed a Derbyshire Local Delivery 21
Roadmap to join up care across the county. This sets out our IM&T objectives, which are shown in Appendix 3, in relation to the STP priority areas.
6.5.7 Business Continuity
The Trust has in place a Major Incident & Business Continuity Plan. In 2016-17, following a peer review from the lead CCG, the Trust received full assurance against NHS England’s Core Standards for Emergency Preparedness, Resilience and Response (EPRR). and maintains and develops business continuity arrangements in line with national guidance and BS25999. In 2014-15, following a peer review from the lead CCG, the Trust received 'full assurance' against the wider Emergency Preparedness, Resilience and Response (EPRR) work programme.
7. Governance and Assurance
7.1 Governor Elections, Training and Development
8 new Public and 3 new Staff Governors commenced their tenure with DCHS on 1st November 2017 with an additional 3 Public and 2 Staff Governors due to commence their tenure on 1st April 2018
Governor training, development and activities to facilitate future engagement and recruitment will include: • Convening elections where vacancies exist • Election “drop in” sessions at locations and DCHS services across the county • An induction programme for new Governors • Articles in members’ newspaper and staff magazine; press releases: social media messages; internet and intranet web content; emails to members; posters; electoral agent electronic election platform; video interviews with Governors • Provision of a “buddy” to ensure the successful integration to the Council • Continued support to Governor groups covering Strategy, Quality, Governance and Engagement • Strategic development workshops and membership engagement activity • Visits to sites and services including the national Governor conference • Governor involvement with community groups such as Patient Participation Groups
7.2 Membership Strategy
As part of the review of the Trust’s Strategy members were consulted directly to obtain their views on the priorities for the Trust and to understand what could be improved upon. As a result of this we will continue to develop our membership strategy by:
• The Trusts Communication and Engagement Team supporting the Patient Experience Team (PET) to engage members in defined protected characteristics projects • Providing a varied programme of quality visits (PLACE) and educational training sessions for our members on popular health-related topics (such as Heartstart) • Regularly contacting members about health events in their area • Strengthening links with a wide range of community and voluntary groups to build a diverse membership • Reviewing members’ engagement in the public session of the Trust Board, supporting the Trust Secretary and Chair to maximise engagement and transparent operation of the Board.
To engage with the wider public we will:
• Actively promote the Board meeting to members and public; including the open question and answer session that precedes the Board
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• Actively promote the Governor elections as and when they arise – through press releases, promotional materials, social media communications and our website. We will additionally actively recruit new members and promote the benefits of trust membership during this time.
7.3 Governance of the Plan
7.3.1 Risks and Enablers
The actions set out within our operational plan reflect new and additional transactional as well as transformational challenges for DCHS. These come at a time of significant system level changes when we are already implementing major programmes of transformational change including implementation of the Better Care Closer to Home programme, internal reviews of service delivery, workforce transformation and the development of new contracting models and arrangements.
Our approach to the delivery of our contractual obligations continues to reflect a high level of clinical scrutiny and demonstrates the strong grip we have on the issues affecting both DCHS and the delivery of transformation across the system. To ensure that we maintain a clinical focus our plans, and supporting strategies, are directly aligned to the principles of the IHI triple aim. In this context we will undertake a risk based approach to the delivery of the plan, based on the detailed understanding of its impact on the capacity of our clinical and corporate teams. This will help us to develop a phased approach to the delivery of our internal change programmes, including the development and implementation of changes to our supporting clinical and corporate strategies.
Despite the significant challenges posed by our contract settlement for 2018/19 we remain committed to the delivery and ambitions of the Derbyshire plan. As such our focus on leadership development, technological transformation and the delivery of our People Strategy will ensure that we are able to meet our own internal plans as well as to support the wider system aspirations. We will also continue to work closely and collaboratively with our partners to support the delivery of a system level approach to risk management ensuring that we maintain a clinical and quality focus as we deliver the plan. As part of this approach we will work closely with colleagues in the STP Clinical Professional Reference Group to support our future decision making and continue to ask that QIPP plans are subject to a comprehensive quality impact assessment.
The challenging financial context means that the effective governance of the delivery of the plan is extremely important and therefore the plan has been structured to reflect the way this will be implemented through the Board’s Quality Service, People and Business committees taking account the key aims of service sustainability, viability, public accountability and transparency.
The monitoring plan, shown in appendix 1, details arrangements for ensuring delivery and ensures that our actions are aligned to our strategic objectives and address any associated BAF risks.
In 2017 we reviewed our BAF risks to ensure these appropriately reflect the challenges we face. Appendix 2 details how the actions contained within the operational plan, along with the objective and priorities of our Derbyshire STP, come together to mitigate these BAF risks and to provide assurance on the continued delivery of the Trusts strategic objectives and therefore the overarching vision and values of the Trust.
During the final quarter of 17/18 an externally commissioned well-led review was undertaken within the organisation. Whilst the outcome of the review was extremely positive a number of further opportunities have been identified to support the continued development of the organisation in relation to the themes of:
• Strategic Direction • Leadership, autonomy and development • Improvement and Innovation • Agile and Governance
Work is taking place at Board level to develop an action plan to support these themes.
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8. Authorisation and Oversight of the Operational Plan The year 2 refresh of the 2017/19 Operational Plan has been developed and reviewed by the Trust’s Executive led Plan Delivery Group, with representatives from all clinical divisions, Medical Director, Chief Nurse and Director of Quality; providing clinical scrutiny and oversight across all elements of the plan.
This refresh has been undertaken in the context of the Board’s work to revise the organisations strategic priorities through a series of developmental sessions. The refresh of the plan has therefore had close Board oversight with regular reporting through the Boards Commercial Development sub group and its formal Quality Business Committee (QBC), as well as through the Governor’s Strategy Sub Group and full Council of Governor’s meetings.
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Appendix 1 –Monitoring Plan
BRAG Rating Triple Aim Escalation Action KPI/Measure Lead (Delivering to time, Notes Objective Required? budget and outcomes) Determined by What we expect to overarching Trust achieve following Operational Plan – completion of the and reflecting action eg the agreed priorities achievement of a specific target, standard or outcome which should be measurable
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Appendix 2 – Board Assurance Framework Risks
BAF Risk Description 17/18 – 18/19 Operational Plan Action Reference Reference Quality Service 1.1/18 There is a risk to patient care due to stretched management capacity and overall service Section 6.5.5 (Commercial Developments) continuity from the processes related to significant service change (including bidding for and acquiring new services the requirement to retender for existing services and transformation of existing services e.g. BCCTH) resulting in a reduced quality of service 1.2/18 There is a risk to patient care due to a failure to optimise use of current information systems Table 3 references - 6, 9, 11, 12, 18 resulting in reduced time to care and inaccurate management information 1.3/18 There is a risk patient care due to a lack of consistent deployment of the Trust’s patient Table 3 references - 1, 2, 15, Section 4.2.1 (Quality quality improvement and assurance framework resulting in care that is less safe and Improvement), Section 5.4 (Workforce), effective 1.4/18 There is a risk to patient care due to a failure to apply evidenced based practice, learn from 1, 2, 3, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 17, 18, 19, 21, 22 clinical governance processes and implement change resulting from audit and feedback resulting in the provision of less effective care 1.5/18 There is an overarching risk to patient care due to periods of major system change and Table 4 references - 1, 15, Section 2 (Strategic and Planning employment of new governance systems and processes related to place based care Context), Section 4.1 (Approach to Quality Governance), resulting in a reduced quality of service Section 4.2 (Quality Planning – creation, assessment and governance), 5.5.4 (Workforce transformation and new models), Section 5.5 (Workforce Governance), Table 4 (inclusive leadership and governance), Section 7 (Governance and assurance) 1.6/18 There is a risk to population health through the failure to fully embed public health principles 7, Section 3.1 (Public Health Organisation), Table 1 (Public within DCHS service delivery resulting in an inability to reduce inequalities for our resident Health Table and actions), Section 5.4.2 (Workforce Planning) communities 1.7/18 There is a risk to patients due to DCHS not consistently considering principles of equality, Section 4.2.2 (Quality Planning – creation, assessment, diversity and inclusion resulting in the way we plan and deliver our services being at odds governance and monitoring), Section 5.6 (Inclusion and fairness with what matters to individuals/ service users/ carers @ DCHS), Table 4 (Equality Objectives) Quality People 2.1/18 There is a risk to patient care due national and local workforce supply shortages resulting in Section 4.2 – Table 2 (Quality Improvement Plan), Section 5.4 our staff not being able to provide high quality, safe and effective care (Workforce) 2.2/18 There is a risk to staff and patient care due to the Trust not having sufficient resources and Section 4.1.3 (Patient Safety), Section 4.2 – Table 2 (Quality capacity to deliver the volume of training required from service changes resulting in a Improvement Plan), Section 5.4 (Workforce) workforce without the appropriate skill set 2.3/18 There is a risk to the Trust due to the high volume of organisational and health system Section 5 (Workforce), Section 6 (Reducing the per capita cost change, which is likely to continue to be a feature of our health economy for several years of healthcare)
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resulting in a reduced organisational performance 2.4/18 There is a risk to staff due to the uncertain operating environment DCHS is working in Section 1 (Introduction and Strategic Approach), Section 3.1 resulting in reduced personal engagement, morale, and health and wellbeing of our staff (Public Health Organisation), Section 4.2 (Quality Improvement Plan) 2.5/18 There is a risk to staff and patient care due to the volume of organisational change resulting Section 1 (Introduction and Strategic Approach), Section 2 from tenders and service changes resulting in our staff not being able to provide high (Strategic and Planning Context), Section 6.5.5 (Commercial quality, safe and effective care Developments), Section 7.3.1 (Risks and Enablers) 2.6/18 There is a risk to the Trust due to the amount of internal transformation affecting our ability Section 1 (Introduction and Strategic Approach), Section 2 to deliver the ambitions in our Leadership Strategy resulting in reduced organisational (Strategic and Planning Context), Section 5.5.4 (Workforce performance Transformation and New Models), Section 5.6 (Inclusion and Fairness @DCHS), Section 7.3.1 (Risks and Enablers) 2.7/18 There is a risk to the Trust due to our inability to establish a culture that embraces inclusion Section 1 (Introduction and Strategic Approach), Section 4 .1.2 and the principles and practice of quality improvement and continual learning resulting in (From Good to Great –Our approach to achieving our ambition), reduced organisational performance Section 4.1.4 (Measures being used to demonstrate and evidence the impact of investment in quality improvement), Section 4.2 (Quality Improvement Plan), Section 5.6 (Inclusion and Fairness @DCHS) Quality Business 3.1/18 There is a risk to the organisation’s performance and in achieving our strategic objectives 1, 2, 5, 6, 7, 9, 10, 11, 12, 14, 15, 16, 18, 21, 22 due to inconsistent implementation / organisational support of the Sustainability and Section 3.1 Public Health Organisation – Table 1, Section 6 Transformation Plan resulting in poor outcomes for patients and poor use of resources (Reducing the per capita cost of healthcare) 3.2/18 There is a risk to the effective and efficient provision of DCHS services due to the financial Section 1 (Introduction and Strategic Approach), Section 2 stress experienced by health and social care partners resulting in unfunded activity being (Strategic and Planning Context), Section 5.4.2 (Workforce directed towards community services, resulting in increasing caseloads and / or increased Planning) Section 6.1.1 (Approach to activity planning), Section waiting times and inequitable outcomes / access 6.1.2 (Achievement of key milestones), Section 6.1.4 (Financial forecasts and modelling) 3.3/18 There is a risk to the financial stability of the organisation due to not meeting the future Section 4.2.2 (Quality Planning – creation, assessment, Sustainable Quality Improvement Programme over the next two years (2018/19 and governance and monitoring), Section 6.1.3 (Financial Planning), 2019/20) and the loss of service contracts, decommissioning of services and / or 6.1.4 (Financial Forecasts and Modelling), Section 6.2 unfavourable contract negotiations resulting in unfunded stranded costs (Efficiency Savings), Section 6.5 (System Efficiency), Section 6.5.5 (Commercial Developments) 3.4/18 There is a risk to the organisation due to non-delivery of elements of the IM&T strategy, Section 6.3 (Capital Investment Plan), Section 6.5.6 (Informatics resulting in the full benefits not being realised and impact on patient care and technological transformation), Appendix 3 – Derbyshire local delivery roadmap 3.5/18 There is a risk to the Trust’s resilience, due to an emergency, severe disruption or a cyber- Section 3.1 (Public Health Organisation – Table 1), Section attack, resulting in an impact on patient care, inability to meet targets, loss of revenue 6.1.2. (Achievement of key milestones), Section 6.5.6 (Informatics and technological transformation), Section 6.5.7
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(Business Continuity) 3.6/18 There is a risk to the organisation, due to failure to align and influence stakeholders Section 1 (Introduction and strategic approach), Section 4 resulting in poor relationships that impact on patient care (Improving the experience of care) Section 5.6 (Inclusion and Fairness @DCHS) 3.7/18 There is a risk to the organisation due to the complexity of running multiple significant Section 6.3 (Capital Planning), Section 6.4 (Estates capital projects resulting in benefits not be delivered in a timely, efficient and effective way Management), Section 6.5.6 (Informatics and technological transformation), Section 7.3.1 (Risks and Enablers) 3.8/18 There is a risk to the organisation due to not being able to undertake transformation at the Section 1 (Introduction and strategic approach), Section 3.1 pace it is required resulting in future loss of patient benefit and resources not being used Public Health Organisation, Section 4.1 .4 (Measures being used effectively to demonstrate and evidence the impact of investment in quality improvement), Section 6.5.6 (Informatics and technological transformation), Quality Governance 4.1/18 There is a risk to the organisation due to not having strong corporate governance systems Section 7.4 (Governance of the plan) in place resulting in Trust vision not being delivered 4.2/18 There is a risk to the organisation due to not meeting regulatory, contractual or legal 11, 12, 13, 15, 16 obligations resulting in sanctions 4.3/18 There is a risk to the organisation due to not having strong risk management controls in Section 7.3.1 (Risks and Enablers) place resulting in failure to put effective mitigation plans in place promptly Appendix 1) 4.5/18 There is a risk to the organisation due to lack of comprehensive data quality systems 6, Section 6.5.6 (Informatics & Technological Transformation) resulting in poor decisions that could affect outcomes and financial loss 4.6/18 There is a risk to the organisation of ineffective Derbyshire system wide governance 7.3.1 (Risks and Enablers) arrangements which may impact on the quality of our services, workforce and business arrangements.
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Appendix 3 Derbyshire Local Delivery Roadmap
Appendix 4 Operational Plan Glossary
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Appendix 4 Glossary
Activity Plans Activity Plans are developed by services to understand what the future demand for services might be and to ensure that there is sufficient capacity to meet the demand and ensure achievement of national waiting time standards. ACP – Advanced Clinical An Advanced Clinical Practitioner is a health professional who has acquired the expert knowledge base, complex decision making Practitioners skills and clinical competencies AHP – Allied Health Allied Health Professionals is a term used to describe a wide range of health professionals, including podiatrists, dieticians, Professional physiotherapists, occupational therapists, radiographers and speech and language therapists Agency Staff/Expenditure Agency staff are an important and widely used resource across the NHS where organisations are temporarily unable to fill certain roles, and used when the role cannot be covered by Bank Staff. Agency use can be expensive and organisations have been set a limit to the amount they can spend on agency workers Assets (current and non- Assets are items held by the organisation. Current assets are those assets that are held as cash or are expected to be converted to current) cash within a year. Non-current assets are held as longer term investments and are not readily convertible to cash. Examples include land and buildings owned by the Trust BCCtH – Better Care Better Care Closer to Home is a transformation programme that will deliver care closer to people’s homes and will change how and Closer to Home where care is provided for patients. Better Care Closer to Home was approved by the Derbyshire Commissioners in 2017 and is currently being implemented Back Office Back office describes the functions such as Information Technology, Human Resources and Finance that are provided in each Trust or CCG Bank Staff Bank staff are a flexible alternative to covering certain roles within an organisation. DCHS bank staff are a flexible workforce bank of temporary workers and can include staff who work substantively for the organisation who work separately from their substantive post or who are registered for bank work with no substantive contract with the Trust Block Contract A block contract is a way for commissioners to pay for NHS services – a fixed sum is paid for the delivery of a service, or a range of service. This differs from a Cost and Volume contract BRAG rating – Blue, Red, A traffic light rating to monitor the progress in delivering a project, scheme or action. Blue identifies an area that has been completed. Amber, Green Capital (Including public Capital expenditure is resources incurred by the Trust in acquiring or maintaining non-current assets such as land and buildings. divided capital) Public Dividend Capital represents the Department of Health’s equity interest in defined public assets across the NHS. Capital service capacity This measure represents the degree to which the Trust can meet its financing obligations, egg the annual dividend payable on average net relevant assets. Care Home Support The Care Home Support team provide improved access to rehabilitation for elderly people living in care homes and helps to reduce falls and admissions to hospital as well as improving wellbeing and confidence Category 1 The highest performance level within the Single Oversight Framework (SOF). Trusts with this category rating are the providers with maximum autonomy, no potential support needs and requiring the lowest level of oversight. CCG – Clinical Clinical Commissioning Groups were established in the Health and Social Care Act 2012 to organise the delivery of NHS services in Commissioning Groups England. 30
CIP – Cost Improvement Plans to reduce the expenditure on or increase the efficiency of a particular activity. CIPs can include recurrent (year on year) or non- Plan recurrent (one-off) savings. Control Total These are Financial Control totals and have been calculated by NHS Improvement on for each Trust and CCG. They are the minimum level of financial performance Trusts are expected to meet this control, or better it. Cost and Volume A Cost and volume contract is a where commissioners pay for an anticipated level of activity, such as number of outpatient appointments or a surgical procedure. Payments are made by commissioners to providers and adjustments can be made based on whether the activity is more or less than was expected. CQC – Care Quality The Care Quality Commission – the independent regulator of health and adult social care services in England that ensures care Commission provided by hospitals, dentists, ambulances, care homes and home care agencies meets government standards of quality and safety CQUIN – Commissioning Commissioning for Quality and Innovation is a payment framework that enables commissioners to reward on-going innovation and for Quality and Innovation improvement in care. CQUINs are set nationally as well as locally. A proportion of income is received on achievement of these targets. Dashboard The performance dashboard is a report used to monitor the Trust’s performance across a range of measures over time as well as an assessment of the quality of the data used Delirium Delirium is a common, serious but often treatable condition that starts suddenly in someone who is unwell. It causes a person to become easily distracted and more confused than normal. Delirium is different from dementia. For someone with delirium, symptoms come on over a matter of hours or a few days. The symptoms of dementia come on slowly, over a period of months or even years. Delirium is much more common in older people, especially those with dementia Decomissioning A decision taken to withdraw funding for a particular service or intervention Depreciation An accounting method to allocating the costs of tangible non-current assets to operating expenditure over it’s useful life DTC - Diagnostic and The DCHS Diagnostic and Treatment Centre is located at Ilkeston Community Hospital and provides a range of specialist treatments Treatment Centre and investigations, including day case procedures DRRT – Dementia Rapid The Dementia Rapid Response Team is a community-based service. The primary aim of the DRRT is to improve the well-being of Response Team people with dementia at times of crisis, by delivering rapid assessment and intensive support. In the process, the team aims to reduce the need for admission into specialist dementia hospital beds. Duty of Candour Duty of Candour is a legal duty on hospital, community and mental health trusts to inform and apologise to patients if there have been mistakes in their duty of care that have led to significant harm. It helps patients receive accurate, truthful information from health providers DHcFT Derbyshire Healthcare NHS Foundation Trust DToC – Delayed Transfers A delayed transfer of care occurs when a patient is ready to leave their current care (acute or non-acute) for home or another form of of Care care but still occupies a bed EBITDA – Earnings before EBITDA – Earnings before Interest, Tax, Depreciation and Amortisation – Is a way of representing how much of our operating income Interest, Tax, Depreciation exceeds our operating costs. The DCHS EBITDA for 16/17 was £11.835 which equates to 6.1%. This measure demonstrates sound and Amortisation financial health and the efficient use of resources. EDS2 – Equality Delivery The Equality Delivery System 2 is a tool designed to help NHS organisations, in partnership with local stakeholders, to review and System 2 improve their performance for people with characteristics that are protected by the Equality Act 2010, and to support them in meeting the Public Sector Equality Duty Elective An elective admission or attendance at hospital is one that has been arranged in advance and is not an emergency admission EQI – Equality Impact An Equality Impact Assessment is a process for identifying the potential impact of policies, strategies and service developments on Assessment our patients, staff and stakeholders 31
Equalities Allies Equalities Allies are anyone – irrespective of characteristic – who wants to support the Trust in progressing the equalities agenda
Extended hours enhanced Extended hours enhanced service requirements are designed to support GPs to provide appointments outside of the core contracted service requirements hours to allow patients to attend appointments at a time when it is more convenient to them. Frailty Frailty is not an inevitable part of aging, although it does become more prevalent with age. It is thought to affect 25 to 50 per cent of people over 80, and about 10 per cent of those over 60. We will work collaboratively with our commissioners and partners in acute and mental health to develop integrated pathways across the ‘pillars of frailty’; that include falls, immobility, delirium and dementia, continence and the side effects of multiple medications ‘polypharmacy’. FT - Foundation Trust A type of hospital or NHS organisation that is independent from the Department of Health. Foundation Trusts are accountable to local people who can become governors and members. They are authorised and monitored by an independent regulator called NHS Improvement (previously Monitor) Geriatric Assessment Geriatric Assessment or Comprehensive Geriatric Assessment is a diagnostic process to determine a frail older person’s needs to enable clinicians to develop an integrated plan for treatment , rehabilitation and support GPFYFV – General The General Practice Five Year Forward View was published in April 2016 and commits extra funding to support general practice Practice Five Year Forward services by 2020/21. It is designed to improve patient care and access with investment in new ways of providing primary care. View IBP - Integrated Business Integrated Business Plan - This document is the overarching strategic and planning document developed in 2014 to successfully Plan support the Trust’s application for Foundation Trust status Income (clinical, other, Income is the money received by the Trust in exchange for the provision of goods and services. The majority of the Trust’s income is deferrered) for the provision of clinical services. Where income is received in advance of the provision of the related goods or services, this income is deferred and matched with the corresponding expenditure incurred in a subsequent accounting period. I&E Income and The I&E Account records the monies coming in and going out of the Trust in the provision of goods and services over a particular Expenditure accounting period. IHI – Institute for healthcare The Institute for Healthcare Improvement is an independent not-for-profit organisation based in Massachusetts, USA and is a leader improvement in driving results in health, and healthcare improvement worldwide Integrated Community Integrated Community Teams are comprised of nursing and therapy services that work together provide coordinated person centred Teams care to help people to remain within their homes and communities and to help people to become as independent as possible after a stay in hospital IV (intravenous) therapy Intravenous therapy is the fastest way to deliver medication and fluid replacement throughout the body. For some patients IV therapy can be provided in people’s own homes to help avoid an admission to hospital, or as part of plan to support the early discharge from an acute hospital. Liabilities The Trust’s financial obligations that arise during the course of normal business operations. Current liabilities are required to be settled within the current financial year. Non-current liabilities will be settled over a longer time period. Liquidity The measure of the extent to which the Trust has cash or equivalent assets that can be converted to meet current liabilities. Mitigation plan A plan which details actions that could be implemented to address the realisation of a financial risk or risks to the organisation. MIUs – Minor Injury Units Minor Injury Units provide treatment for less serious injuries such as deep cuts, eye infections, broken bones, severe sprains, minor head injuries and minor burns and scalds. MCP Multi Specialty Multi-Specialty Community Provider – one of the new models of care outlined in the NHS Five Year Forward View. MCPs enable GP Community Provider practices to come together to collaborate with other health and social care professionals to provide more integrated care outside of hospitals 32
National efficiency The level of efficiency savings required of NHS providers in any given year. NHSI – NHS Improvement NHS Improvement is responsible for overseeing foundation trusts and NHS trusts, as well as independent providers that provide NHS-funded care. NHSI was formed in 2016 and brought together a range of organisations including Monitor, The Trust Development Authority, Patient Safety, Advancing Change Team and the Intensive Support Team Non-Elective A non-elective admission described an unplanned, often urgent admission to hospital , often as a result of attending A&E NQB- National Quality The National Quality Board is comprised of the partner organisations who developed the Five Year Forward View (NHS Improvement, Board NHS England, the Care Quality Commission, Health Education England and Public Health England and the Department of Health). The NQB is a forum where the key NHS oversight organisations can come together regionally and nationally to share intelligence, agree action and monitor assurance on quality. Operating expenses The costs associated with the Trust’s main activities on a day to day basis. Organic An organic disorders occur as a result of damage to or diseases of the brain. They can affect memory and other functions. Dementia, including Alzheimer’s Disease is an organic mental illness Pay and Prices The impact on the Trust’s cost base of inflationary pressures in relation to pay and non-pay expenditure Personal Health Budgets A personal health budget is an amount of money to support the identified healthcare and wellbeing needs of an individual, which is planned and agreed by the individual, or their representative, and the local clinical commissioning group. It is not new money, but a different way of spending health funding. Personal health budgets can give people with long term health needs and disabilities more choice and control over the money spent on meeting their health and wellbeing needs. Place based care Place based care describes how we will work to move away from care delivered in institutions and beds and to co-ordinate care around people in their own homes and communities. We will work to tailor services that meet the needs of the different communities we serve. Price Cap Price caps are set by NHS Improvement and apply to the total amount a trust can pay per hour for an agency worker Priority Standards for seven The Medical Royal Collages have identified four standards that will have the most impact on reducing weekend mortality, and should day hospital services therefore be of immediate focus for NHS Trusts. These standards are: Time to consultant review, Access to diagnostics, Access to consultant-directed interventions, On-going review QIA – Quality Impact All service changes that are proposed within DCHS are subject to a Quality Impact Assessment. This process involves reviewing the Assessment proposed changes against a range of domains including patient safety, clinical effectiveness , patient experience and the impact it may have on others – including staff, stakeholders and reputation. All QIAs are signed off by the Chief Nurse and Director of Quality, Medical Director and a Non-Executive Director. QIPP – Quality Innovation, The Quality, Innovation, Productivity and Prevention programme is a large scale programme developed by the Department of Health Productivity and Prevention to quality improvements in NHS care at the same time as making financial savings. SOF – Single Oversight The Single Oversight Framework is designed to help NHS providers attain and maintain Care Quality Commission (CQC) ratings of Framework ‘Good’ or ‘Outstanding’. Providers are given a category or segment that determines the level of support each Trust needs based on five themes – quality of care, finance and use of resources, operational performance, strategic change and leadership and improvement capability Reserve Contingency held to meet unforeseen financial pressures Retained earnings The cumulative surplus or deficit position of the Trust RTT – Referral to The NHS Constitution gives patients the ‘right to access certain services commissioned by NHS bodies within maximum waiting Treatment times or for the NHS to take all reasonable steps to offer a range of suitable alternative providers if this is not possible’. The NHS constitution sets out that patients should wait no longer than 18 weeks from GP referral to treatment Sensitivity – combined A scenario that is applied to the Trust’s base case financial plan, to assess the impact that the realisation of a number of key risks 33 scenario would have on the financial projections. Slippage Delays in savings schemes and or investment plans Step Up Step up facilities can be used when a patient needs more support and care, such as admission to a community hospital bed STP - Sustainability and Sustainability and Transformation Partnerships (previously known as Sustainability and Transformation Plans) were introduced to Transformation help local health and care services to evolve and become more sustainable and to progress the delivery of the NHS Five Year Partnership Forward View vision of improving health and wellbeing, the quality of care and improved efficiency Sign up to Safety Sign up to Safety is a national patient safety initiative to help NHS organisation and their staff achieve their patient safety aspirations Campaign and care for their patients in the safest way possible Surplus A surplus is achieved when the income received in the provision of goods and services exceeds the costs of delivering the same goods and services. Stranded Costs Infrastructure and overhead costs that are irrecoverable following change in service provision and where the income is no longer sufficient to cover these costs. System Efficiency How we improve the efficiency of the health system – including how we use our buildings, reduce duplication, reduce reliance on agency staff etc System Management System Management describes how public sector organisations – NHS and Social Care work together, across the county to remove inefficiencies associated with organisational boundaries Teachable Moments Teachable Moments is an approach to support an individual’s desire to change health behaviours, such as stopping smoking, that can be associated with naturally occurring events in people’s lives such as illness, or the birth of a baby. Technical Efficiency The production of the maximum output from a given amount of input. Telehealth Telehealth is a process of using electronic information and telecommunication to provide and support health related services. It has the potential to transform the way people engage in and control their healthcare and enable care to be delivered in a more convenient and cost effective way. TPP - SystmOne The Phoenix Partnership (TPP) is a software company that develop and supply clinical software – such as SystmOne. SystmOne is the IT system used by DCHS to provide integrated electronic patient records to help out clinicians deliver the highest quality clinical care Trust Base Case Plan The most realistic and likely financial position given a set of circumstances and with reasonable assumptions. Trusted Assessment Trusted assessment is a key element of best practice in reducing delays for people awaiting discharge from hospital and help them to move from hospital back home or to another setting speedily, effectively and safely Unified Community An approach to providing integrated community-based person centred support for those people living with complex and multiple Learning Disability model needs; ensuring care supports their independence, choice and inclusion Unwarranted Variation Variation in healthcare is to be expected such as providing different types of service to meet the needs of different populations – this is known as warranted variation. However, some types of variation can be unacceptable for patients, carers and the services that support them such as differences in waiting times . By tackling these unwarranted variations we can help deliver improved care more efficiently. Well Led Review ‘Well Led’ is one of the five key questions the Care Quality Commission (CQC) considers when inspecting health and social care services. The other areas reviewed by the CQC are whether services are safe, caring, effective and responsive to people’s needs.
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