Poole Hospital NHS Foundation Trust Use of Resources report Date of site visit: Longfleet Road, Poole, Dorset BH15 2JB 6 October 2017 Tel: 01202 665511 Date of publication: www.poole.nhs.uk 2 August 2018 This report describes NHS Improvement’s assessment of how effectively this trust uses its resources. It is based on a combination of data on the trust’s performance over the previous 12 months, our local intelligence, the trust’s commentary on its performance, and qualitative evidence collected during a site visit comprised of a series of structured conversations with the trust's leadership team. How effectively is the trust using its resources? Good How we carried out this assessment The aim of Use of Resources assessments is to understand how effectively providers are using their resources to provide high quality, efficient and sustainable care for patients. The assessment team has, according to the published framework, examined the trust’s performance over the previous 12 months against a small number of initial metrics, alongside local intelligence from NHS Improvement’s day-to-day interactions with the trust, and the trust’s own commentary and information on its performance. The team conducted a dedicated site visit to engage with key staff using key lines of enquiry (KLOEs) and prompt questions in the areas of clinical services; people; clinical support services; corporate services, procurement, estates and facilities; and finance. All KLOEs, initial metrics and prompts can be found in the Use of Resources assessment framework. We visited the trust on 6 October 2017 where we met the trust’s leadership for discussions based on key lines of enquiry and prompts. The participants included the executive team (including the Chief Executive), a non-executive director (in this case, the Chair) and relevant senior management responsible for the areas under this assessment’s KLOEs. 20171123 Poole Hospital NHS FT Use of resources October 2017 1 Summary of findings Is the trust using its resources productively to Good maximise patient benefit? We rated use of resources as Good because the trust is achieving good use of resources, enabling it to provide high quality and sustainable care for patients: For the year ended 31 March 2017, the trust reported a surplus of £0.9m, which exceeded the trust’s plan and the target (referred to as the ‘Control Total’) set by NHS Improvement. The trust is on track after the first three months of the 2017/18 financial year to deliver its Control Total of £3.1m deficit. This means that the trust is meeting its overarching financial obligations as set out by NHS Improvement. The trust manages its finances so that it is not reliant on extra cash support in order to meet its obligations. The trust spends less on pay and other goods and services per weighted unit of activity (WAU) than most other trusts. This indicates that the trust is more productive at delivering services than comparable trusts by showing that, on average, the trust spends less to deliver the same number of services. The trust is working with Dorset Clinical Commissioning Group (CCG) and other NHS providers in Dorset to implement the Dorset Clinical Services Review which will lead to the trust focus being on planned care in the future. The trust demonstrated examples of innovation and good practice, including its work with the Local Authority on discharge processes, use of allied healthcare professionals (AHPs) in the Musculo- Skeletal pathway, focus on its medicines programme, the involvement of clinicians in procurement, and its financial management. The trust also outlined areas in which it has already worked with other health bodies in Dorset to get better value for money through joint procurement exercises. However: The trust is planning to move from a balanced budget to a 1.3% deficit position by the end of the 2017/18 financial year. It also believes its long term financial sustainability as a standalone organisation is uncertain. The trust is not currently meeting the national operational performance standard for A&E, in August 2017 the trust achieved 91.7% against the 95% standard. Further work is required with its population to consistently reduce Did Not Attend rates. Benchmarks for doctor and AHP costs are high, with the trust in the highest cost quartile for these pay areas per WAU. This metric suggests that the trust needs to do more work to understand whether this is a warranted variation for the services it provides. How well is the trust using its resources to provide clinical services that operate as productively as possible and thereby maximise patient benefit? Fewer patients are coming into hospital unnecessarily prior to treatment compared to most other similar hospitals in England. The trust is performing in the lowest (best) quartile compared to national averages and its peer group in relation to pre-procedure non-elective days, and is looking at ways of improving this further, eg the fractured neck of femur pathway is being reviewed to increase the percentage of patients treated within 36 hours. Performance is above (better than) the median for elective pre-procedure bed days, and the trust is reviewing cases where patients have been brought into hospital the night before a procedure to identify further improvements to reduce the incidence of where this is clinically unnecessary. Patients are less likely to require additional medical treatment for the same condition at this trust compared to similar trusts. Readmission rates at 7.06% in the first three months of 2017/18, compare well (better than median) against peers. The most recent information (August 2017) shows the trust met its core operational performance standards for Referral to Treatment and cancer, however it did not meet its A&E performance standard, with 91.7% of patients being admitted, transferred or discharged within 4 hours of arrival at the A&E department against the 95% standard. 20171123 Poole Hospital NHS FT Use of resources October 2017 2 The trust reports a fluctuating position for Outpatient Did Not Attend (DNA) rates, however the most recent data, (at 7.42% for the first three months of 2017/18) is better than the median when compared to the national average, with a rate of 7%. The trust has an improvement plan in place, under which it is working to avoid multiple changes to appointment times, and is reviewing data to identify the themes and trends of non-attendance relating to administrative processes. The trust reports a higher than target Delayed Transfers of Care (DTOC) rate of 3.75% (August 2017), however there has been an overall downward trend in DTOC rate over the last 12 months, with DTOCs peaking at 5.67% (in November 2016). During the site visit the trust described its approach to planning discharge, transfer and transition to improve this position, including reviewing good practice in a neighbouring trust, creation of an integrated discharge hub, working with the Local Authority and local community services provider, and improved internal processes to ensure senior managers are made of aware of the daily bed availability and potential discharges by 10am every day. The trust described innovative work to provide the Trusted Assessor role using therapists and registered nurses via a registered training programme, which enables staff to refer patients for simple packages of care. The trust acknowledged the need to embed this work further and to engage a wider group of staff to support more patients to return home faster. The SAFER patient care bundle (a tool to reduce delays to patients in inpatient wards) needs to be embedded and spread over a wider range of services in the trust, although it reports that staff engagement is good. This is supported by the trust’s staff survey engagement results for 2016 where it benchmarked above average for overall staff engagement. The trust is working with an external clinical productivity specialist company to improve its theatre productivity. The benefit of using the ‘Getting It Right First Time’ (GIRFT) programme has been limited because only 9% of the trust’s activity is elective and, to date, the most advanced GIRFT programme is in elective trauma and orthopaedics, which the trust does not provide. The trust did describe some learning from the programme across its fractured neck of femur pathway leading to a reduction in the readmission rate for flap reconstruction which the trust has already implemented. It was acknowledged that there will be more opportunities to improve when further national GIRFT data is released, to develop this work in other areas. How effectively is the trust using its workforce to maximise patient benefit and provide high quality care? The trust was within its agency staff ceiling in 2016/17 and believes it will be within its ceiling again in 2017/18. However, the trust has recently undertaken a review of the nursing establishment, resulting in an increase in supervisory time for some band 7 / ward manager staff, which has led to an increase in the use of temporary staff whilst recruitment plans are implemented. Staff retention rates are above (better than) the national median, and currently around 87% (August 2017). The trust has a non-executive chaired ‘Workforce and Organisational Development committee’ which reports directly to the Board as the trust actively recognises the importance of its staff to the service it delivers. The Board sees a monthly integrated quality, performance and workforce report. Following the appointment of a new HR director, the trust is reviewing its workforce and a people strategy is being developed to increase focus on improving overall staff experience. An HR business partner has also been seconded to focus on actions relating to staff recruitment and retention.