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Lewisham & Greenwich NHS Trust Lewisham & Greenwich NHS Trust Use of Resources assessment report University Hospital Lewisham High Street Lewisham Date of publication: London 11th January 2019 SE13 6LH Tel: 020 8333 3000 https://www.lewishamandgreenwich.nhs.uk/ This report describes our judgement of the Use of Resources and our combined rating for quality and resources for the trust. Ratings Overall quality rating for this trust Requires improvement Are services safe? Requires improvement Are services effective? Requires improvement Are services caring? Good Are services responsive? Requires improvement Are services well-led? Requires improvement Our overall quality rating combines our five trust-level quality ratings of safe, effective, caring, responsive and well-led. These ratings are based on what we found when we inspected, and other information available to us. You can find information about these ratings in our inspection report for this trust and in the related evidence appendix. (See www.cqc.org.uk/provider/RF4/reports) Are resources used productively? Requires improvement Combined rating for quality and use of Requires improvement resources We award the Use of Resources rating based on an assessment carried out by NHS Improvement. Page 1 of 16 Our combined rating for Quality and Use of Resources summarises the performance of the trust taking into account the quality of services as well as the trust’s productivity and sustainability. This rating combines our five trust-level quality ratings of safe, effective, caring, responsive and well-led with the Use of Resources rating. Use of Resources assessment and rating NHS Improvement are currently planning to assess all non-specialist acute NHS trusts and foundation trusts for their Use of Resources assessments. The aim of the assessment is to improve understanding of how productively trusts are using their resources to provide high quality and sustainable care for patients. The assessment includes an analysis of trust performance against a selection of initial metrics, using local intelligence, and other evidence. This analysis is followed by a qualitative assessment by a team from NHS Improvement during a one-day site visit to the trust. Combined rating for Quality and Use of Resources Our combined rating for Quality and Use of Resources is awarded by combining our five trust-level quality ratings of safe, effective, caring, responsive and well-led with the Use of Resources rating, using the ratings principles included in our guidance for NHS trusts. This is the first time that we have awarded a combined rating for Quality and Use of Resources at this trust. The combined rating for Quality and Use of Resources for this trust was requires improvement, because: • we rated safe, effective, responsive, and well-led as requires improvement; and caring as good; • we took into account the current ratings of the four core services across the two locations not inspected at this time. Hence, six services across the trust are rated overall as requires improvement, and the remaining two services are rated good; • the overall ratings for each of the trusts acute locations remained the same; and • the trust was rated requires improvement for Use of Resources. Page 2 of 16 Lewisham & Greenwich NHS Trust Use of Resources assessment report Date of site visit: University Hospital Lewisham 19 September 2018 High Street Lewisham Date of publication: London 11th January 2019 SE13 6LH Tel: 020 8333 3000 https://www.lewishamandgreenwich.nhs.uk/ This report describes NHS Improvement’s assessment of how effectively this trust uses its resources. It is based on a combination of data on the trust’s performance over the previous twelve months, our local intelligence and qualitative evidence collected during a site visit comprised of a series of structured conversations with the trust's leadership team. The Use of Resources rating for this trust is published by CQC alongside its other trust-level ratings. All six trust-level ratings for the trust’s key questions (safe, effective, caring, responsive, well-led, use of resources) are aggregated to yield the trust’s combined rating. How effectively is the trust using its resources? Requires improvement How we carried out this assessment The aim of Use of Resources assessments is to understand how effectively providers are using their resources to provide high quality, efficient and sustainable care for patients. The assessment team has, according to the published framework, examined the trust’s performance against a set of initial metrics alongside local intelligence from NHS Improvement’s day-to-day interactions with the trust, and the trust’s own commentary of its performance. The team conducted a dedicated site visit to engage with key staff using agreed key lines of enquiry (KLOEs) and prompts in the areas of clinical services; people; clinical support services; corporate services, procurement, estates and facilities; and finance. All KLOEs, initial metrics and prompts can be found in the Use of Resources assessment framework. We visited the trust on 19 September 2018 and met the trust’s executive team (including the chief executive), a non-executive director (in this case, the chair) and relevant senior management responsible for the areas under this assessment’s KLOEs. Page 3 of 16 Findings Is the trust using its resources productively to Requires improvement maximise patient benefit? We rated use of resources as requires improvement because the trust does not consistently manage its resources to allow it to meet its financial obligations on a sustainable basis and to deliver high quality care. • The trust failed to achieve its financial plan in financial year 2017/18, achieving a deficit of £61.8m against an originally planned deficit of £39.4m excluding sustainability and transformation funding (STF). As a consequence of its deficit position, the trust is significantly reliant on external cash support (loans) in order to meet its financial obligations and pay its staff and suppliers in the immediate term. As part of the failure to deliver against plan in the previous financial year, delivery of the trust’s Cost Improvement Programme (CIP) was materially short of plan (delivering £18.9m against an original plan of £47.6m). £11.8m (62%) was delivered recurrently. • We note that the planning for 2017/18 was poor, and that the plans while stretching may not have been deliverable at the time; this resulted in an outturn materially adverse to that original plan. We note that the trust delivered against a revised financial plan that was agreed midway through the 2017/18 financial year. Moreover, the trust has undertaken a more robust planning exercise for 2018/19. • The trust understands the drivers of its deficit and is able to evidence CIPs for financial year 2018/19 are aligned to the these; for example, workforce costs and the cost of delivering emergency activity are key areas for efficiencies in the current year. The plan for the current financial year (2018/19) on a reported basis is a deficit of £53.1m which improves on the prior year by 14.2%. On an underlying basis, the trust is forecasting to improve their position from a deficit of 62.5m in 2017/18 to 46.8m in 2018/19; a material improvement of 25.1%. We note that the trust is currently on track to deliver this plan. • The trust’s overall cost per weighted activity unit (adjusted for Market Forces Factor) for 2016/17 is £3,604 against a national median of £3,484; this metric places the trust in the third quartile overall. This is largely driven through higher pay costs; we note the trust has challenges in pay controls, use of agency staff, challenges in recruitment and retention. It has begun to deal with these, launching a recruitment strategy in April 2018. While some improvements can be evidenced, including better retention rates, we note that the trust is in the early stages of implementing on many of these schemes and accordingly results are not yet conclusive. • While the trust has failed the Accident and Emergency (A&E) standard in all the previous 12 months, performance in July 2018 was 90.39%, which was better than the national median of 88.96%. This outcome has been delivered while dealing with the challenges of working across two large A&E sites and dealing with multiple commissioners and Local Authorities. • In addition, we noted a number of areas where the trust benchmarks well nationally or can illustrate best practice. These include: o The trust performs better on both elective and non-elective pre-procedure bed days than the national median, suggesting that fewer patients are coming into hospital prior to both planned and emergency treatment. Page 4 of 16 o the Frailty pathway- the trust has developed specialist services at both hospitals to ensure that older people who come through our emergency departments receive an early comprehensive assessment of all their needs and support from a specialist team for older people. o Flow and reduction in length of stay (LoS) on the Lewisham site. o The medicines cost per Weighted Activity Unit (WAU) and the pharmacy staff cost per WAU. The trust has also put in place an outsourced pharmacy on the Lewisham site. This has moved the trust to technician led dispensing, freeing up pharmacists to spend more time on the wards. Patient satisfaction has increased as outsourcing has improved waiting times. o The cost of the finance function in the context of a short timeframe for financial close- down and being able to negotiate a significantly better contract position with its commissioners for financial year 2018/19. o The level of critical infrastructure risk and backlog maintenance. • Finally, there are further areas where the trust can show improvement. Sustaining improvements and delivering outcomes relating to the work undertaken in these areas should remain a key area of focus for the trust.
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