Strategic Plan Document for 2013-14 NHS Foundation Trust · Strategic Plan 2013 – 16 1 1. Executive Summary This Strategic Plan 2013-16 sets out how Salisbury NHS Foundation Trust

Strategic Plan Document for 2013-14

NHS Foundation Trust

Strategic Plan for y/e 31 March 2014 (and 2015, 2016)

This document completed by (and Monitor queries to be directed to):

The attached Strategic Plan is intended to reflect the Trust’s business plan over the next three years. Information included herein should accurately reflect the strategic and

operational plans agreed by the Trust Board. In signing below, the Trust is confirming that: • The Strategic Plan is an accurate reflection of the current shared vision and strategy of the Trust

Board having had regard to the views of the Council of Governors; • The Strategic Plan has been subject to at least the same level of Trust Board scrutiny as any of

the Trust’s other internal business and strategy plans; • The Strategic Plan is consistent with the Trust’s internal operational plans and provides a

comprehensive overview of all key factors relevant to the delivery of these plans; • All plans discussed and any numbers quoted in the Strategic Plan directly relate to the Trust’s

financial template submission. Approved on behalf of the Board of Directors by: Name (Chair)

Luke March

Signature

Approved on behalf of the Board of Directors by:

Name (Chief Executive)

Peter Hill

Signature

Approved on behalf of the Board of Directors by: Name (Finance Director)

Malcolm Cassells

Signature

Name Laurence Arnold

Job Title Director of Corporate Development

e-mail address [email protected]

Tel. no. for contact 01722 336262 ext. 2759

Date 30th May 2013

Strategic Plan 2013 – 16

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1. Executive Summary

This Strategic Plan 2013-16 sets out how Salisbury NHS Foundation Trust (SFT) will take forward its strategic direction and how it will deliver on its vision of providing an ‘outstanding experience for every patient’.

The Trust has agreed a long term strategy which sets out the direction of travel over the next 5 years. The strategy document will be reviewed regularly to ensure that it remains an appropriate and relevant foundation around which high quality, high value developments can be planned.

The document describes the Trust’s strategy built around four key themes (Choice, Partnership, Our Staff and Value) setting out the challenges which the Trust faces in the coming years. Recent experience and expected demographic changes indicate that increases in demand, particularly for non-elective services, will have to continue to be met. This necessitates the Trust being flexible and adaptable and ensuring that services are designed to meet the needs of patients. As section 2.7 shows the population served by SFT is expected to increase and the proportion of elderly people will continue to exceed the national and regional averages, increasing both the volume and the acuity of patients attending SFT. Growing demand at a time of constrained finances similarly necessitates that the Trust work closely with the new Clinical Commissioning Groups (CCG’s) on developing joint pathways which will support commissioners in managing demand on secondary care (especially emergency) services by standardising referral protocols. Partnership with CCG’s is also expected to lead to some increase in elective market share as tertiary activity is repatriated and as the Trust expands the population it serves in key geographical areas. As it has since it was first authorised as an FT, the Trust will ensure that its primary focus remains on the quality of services provided, whilst striving to increase efficiencies wherever possible. Use of the assurance framework will ensure that clinical and quality governance requirements are delivered, and that any potential concerns are flagged at an early stage A three year cost improvement programme (CIP’s) will be co-ordinated by the Trust’s newly formed Programme Management Office (PMO) as the Trust looks to achieve the £8-9m a year it will require to deliver an acceptable level of surplus. Quality impact assessments will be undertaken to ensure that in the pursuit of cost improvement, the focus on patient safety and experience is not compromised. Performance against targets will be closely monitored to ensure that the Trust continues to provide the high quality of care which our users have the right to expect. Foundation Trust Governors have been actively involved in the development of the Trust’s long term strategy, quality priorities and preparation of this document, thereby ensuring that contributions and concerns from our members are used to inform strategic decisions. Implementation of the Trust’s financial strategy will ensure that the Trust retains its financial risk rating (FRR) of at least 3 over the lifetime of this plan with a growing surplus predicted.


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2. Strategic Context & Direction

2.1. Introduction Salisbury NHS Foundation Trust (SFT) is a well-established acute Trust with a track record of delivery. It provides a broad portfolio of acute district general hospital (DGH) services for the local population alongside a focused portfolio of highly regarded specialist services, such as burns and plastic surgery, the Duke of Cornwall Spinal Injuries Unit and the Wessex Genetics Laboratory, to a wider catchment. This portfolio distinguishes SFT from neighbouring Trusts. At one level SFT is a unique local acute hospital service embedded in the local community, whilst on the other its specialist services enjoy a national reputation and reach which extends across much of southern England. The two elements are interdependent – with neither able to prosper without the contribution of the other. SFT is well-known for the excellent patient experience it offers and the Trust has chosen to build its strategy around that priority as described below.

2.2. SFT Strategic Plan The Trust reviewed its strategic direction during the second half of 2012 and the strategic plan, which emerged from that work, was agreed by the Board in March 2013. Salisbury NHS Foundation Trust’s vision is to offer:

An outstanding experience for every patient Underpinned by a total commitment to a high quality of care, the plan for achieving our vision will focus on four key elements:

Choice We will provide a comprehensive range of high quality local services, enhanced by developing our specialist services portfolio, which patients choose to access for their responsiveness, effectiveness and reputation

Partnership We will work closely with our partners to provide safe and well-coordinated care in the most appropriate location for our patients’ needs

Our Staff We will continue to develop a high quality, compassionate and innovative workforce proud to work at SFT

Value We will provide efficient and effective services which deliver the best possible care for patients

The Trust’s vision sets the challenge of providing every patient an outstanding experience in his or her interaction with SFT. This is a challenge which will require the Trust to be truly responsive, to put quality of care at the heart of all we do, to offer high standards of customer care and to listen to feedback from our patients and their carers, from our commissioners and from organisations with whom we work. At the same time, given that we only deliver a part of our patient’s care pathway, we need to work better across organisational boundaries. The best possible care on a ward within SFT will soon be forgotten if the patient is quickly readmitted because the discharge was not planned effectively and the required community support is not in place. Similarly, by working collaboratively with other organisations, we can offer alternatives to hospital admission for patients who do not require acute intervention and can be managed more effectively in the community, preferably in their own homes.


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We will need to develop the staff who can deliver such models – working with and listening to them to build up services which are capable of meeting these challenges head on. SFT’s future plans will be based on delivering this strategy – there is a clear workplan of the key tasks which SFT needs to address to cement its place in the local healthcare community. The strategy will form the basis for future decision-making – new developments or initiatives will be assessed against their contribution to the delivery of the Trust strategy and will form the basis for departments’ service plans and from there ultimately to form the basis of individuals’ annual objectives and personal development plans. We will keep the strategy under review, both in terms of progress against plan and in relation to its continued relevance given the changing environment. The following diagram sets out the factors SFT reviewed in drafting this strategy:

2.3. The Local Health Economy Salisbury NHS Foundation Trust (SFT) is located in the centre of the southern region of NHS England (formerly known as the NHS Commissioning Board). It is on the periphery of three CCG’s (Wiltshire, West Hants and Dorset, Bournemouth and Poole), on the southern tip of the Bath, Gloucester, Swindon & Wiltshire Area Team, and outside of the Wessex Local Education and Training Board (LETB) with whom it will continue to have close links. Specialist commissioning for SFT will be administered by the South West Specialist Commissioning Group. These changes provide opportunities for the Trust to expand the boundaries of its catchment area for both general and specialist services. The NHS structural changes also present the Trust with challenges related to being on the periphery of a number of CCG’s, LETB’s and Area Teams. Key strengths

• Patient experience /staff satisfaction • Community support / Improvement programmes • GP relationships – Brand, reputation • Market leadership – dominant provider in core market in most specialities • Specialist services – plastics, burns, spinal injuries, rehabilitation • Benchmarking – favourable readmission rate, high day cases in some areas • Strong financial performance – low reference cost index (RCI) overall many specialities,

profitability (surgery, musculo-skeletal)


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Weaknesses

• Catchment population – small/mid-sized acute Trust, clinical sustainability (e.g. acute surgery) • Acute portfolio – local community services provided by GWH which means SFT cannot influence

provision of service locally • Benchmarking – LOS in some specialties, FUN ratios in some areas • Elderly population/Long LOS for medicine - lack of local step-up/down or intermediate beds • ‘Block’ contract – income recovery for work undertaken / protection of competing ISTC • Location – single site organisation on border of 3 CCG’s

2.4. Overview of key competitors New Hall Hospital (Ramsay) is the Trust’s closest competitor. Medical Staff are predominantly SFT consultants. Over the past 8 years, there has been a greater focus on NHS activity. A combination of shorter waiting times and proactive marketing and advertising has resulted in NHS patients choosing to be treated at New Hall, for elective surgery. Royal United Hospital Bath (RUH) Over recent years, RUH has lost elective market share to SFT & GWH. RUH is located closer to the ISTC at Emmerson’s Green, and the Circle Hospital in Bath, so there is a high level of competition from the independent sector for NHS activity. Great Western Hospital, Swindon (GWH) Position is strengthened by the award of a contract to run community services in Wiltshire (due to be retendered in 2014). This contract covers the community hospitals in Wiltshire, and therefore provides GWH with access to “step down” beds for patients who are medically fit to be discharged from hospital, but unable to return home. Over the past three years, GWH has gained market share within Wiltshire, particularly from Devizes GP practices. Royal Bournemouth and Christchurch Hospitals (RBCH) Foundation Trust which is heavily focussed on providing elective care. RBCH is currently working towards merging with Poole (subject to the outcome of to Competition and Co-operation Panel (CCP) review). SFT competes with RBCH for activity from the practices in Ringwood, Verwood and, to a lesser extent, Blandford. SFT has network arrangements with RBCH to provide on call rotas in stroke and vascular services. Arrangements are also in place to provide joint care for some patients who require interventional cardiology. UK Specialist Hospitals (UKSH) – acquired by Care UK in February 2012. Two UKSH hospitals (Devizes and Shepton Mallet) are located within SFT’s catchment area. The UKSH facility in Devizes currently benefits from the guaranteed payment contract. The Devizes facility is for day cases and is popular for Orthopaedics, Ophthalmology, Dental, ENT, Endoscopy and Urology. Southampton University Hospitals NHS Foundation Trust (SUNHSFT) Gained FT status in 2011. Provides a full range of general and emergency services to a population of around 1.3 million people in Southampton (44.5% of activity) and Hampshire (44% of activity). Was designated major trauma centre with SFT as a partner in 2012. Is also a major centre for research. SUNHSFT provides a number of tertiary services including neonatal and children’s intensive care services, neurosciences and cardiac services to a population of around 3 million people. Specialist commissioning represents a high proportion of the Trust’s activity. UHSFT is SFT’s nearest cancer centre. The Trust’s work closely to provide cancer services to the SFT catchment population and have shared MDT’s and specialist MDT’s. Hampshire Hospitals NHS Foundation Trust (HHFT). Formed in January 2012 when Andover, Winchester and Basingstoke hospitals merged to become a single organisation. The Trust serves a population of around 600,000 people in Hampshire and West Berkshire and has an annual turnover of around £300m. SFT competes with Winchester for referrals from Stockbridge, Ludgershall and Andover.

2.5. Demographic and demand changes The population of Wiltshire is projected to increase by 18.2% between 2001 & 2026, with the highest growth expected to be in the North of the county. Growth in Westbury, Trowbridge and Devizes will


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have an impact on SFT whereas growth in Calne, Corsham and Melksham will have more of an impact on secondary care services in Bath and Swindon. Wiltshire’s population is heavily weighted towards older age groups (2011 - 19.5% 65 years+ compared to England average of 16.7%), and this is projected to increase over the next 10 years (2021 – 23.4% 65 years+ compared to England average of 19.1%) which is likely to have a significant impact on the health and social care needs of the population served by SFT. Life expectancy for those living in Wiltshire is higher than the South West and England (79.6 males & 83.7 females), although life expectancy is 6 years lower for men and 4 years lower for women who live in the most deprived areas of the county. Fertility rates are higher than average (Wilts 2.27; South West 1.95, England 1.96). A further increase in the population of South Wiltshire will result from the closure of military bases in Germany which will see 4,000 military personnel plus their dependents relocated to bases around Salisbury Plain. SFT needs to factor these changes into activity plans as the majority of troops will be stationed on the southern edge of Salisbury Plain. The greatest impact is likely to be seen in maternity and musculoskeletal services, although the exact timescales are not yet clear and likely to be at the tail end of this plan.

2.6. Impact of market share trends SFT monitors referrals from key practices and competitor activity on a quarterly basis and reports this to the Finance Committee. The Trust’s strategy is to increase market share at the periphery of the catchment area. Over the past 3 years, SFT’s patient spell activity has declined by 5% and this is primarily as a result of a reduction in elective day case activity. Market share and has been lost to the ISTC’s and New Hall Hospital. The cessation of the ISTC contract in 2015 provides the Trust with an opportunity to compete with other providers for this activity. The Trust’s non-elective market share has increased slightly over the past 3 years. Strategically, this is viewed as the Trust’s “natural” market share which is 65% among core practices, whilst the elective market share from the same practices is 52%. Reducing this gap is a key focus for SFT and forms an essential part of the Trust’s marketing strategy which aims to increase elective market share by 3% by 2014/15.

2.7. Threats and opportunities from changes in local commissioning intentions Changes to commissioning strategy & intentions SFT has, in the current year, enjoyed closer relationships and improved communication with the three CCG’s who are the Trust’s main commissioners. The Trust’s second largest contract in terms of monetary value is now with the Specialist Commissioners QIPP & demand management The contract with Wiltshire CCG includes an element for QIPP of some £1.5m. By far the largest proportion is for a reduction in non-elective admissions. This is largely the CCG’s risk, since SFT will continue to be paid for activity which it is required to perform. SFT will monitor carefully the impact of the initiative and will close capacity as a result of any step reduction in non-elective admissions. Under QIPP, SFT has agreed to reduce the number of follow up outpatient appointments offered, particularly within the specialty of orthopaedics.


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Any Qualified Provider (AQP) To date, SFT has successfully qualified as a provider for two AQP initiatives – one to provide a lymphoedema service for Wiltshire CCG and the other to provide elective surgical services for Swindon and Gloucestershire CCG’s. Opportunities to qualify to be a provider of services under the AQP initiative are monitored by contracting and procurement teams with executive directors providing guidance on whether applications should be submitted. Shifting settings of care Centrally driven proposals to combine health and social care are being monitored with interest. The Trust wants to deliver a more integrated model of care which would be effective in reducing non-elective admissions and facilitate earlier discharge. CQUINs have been developed around this work. Changes to pathways for older people with a community geriatrician have been developed and rapid access clinics introduced. Increasing the use of telehealth and the provision of acute care at home are being considered. SFT is working with commissioners in Wiltshire, Dorset and Hampshire to explore how models of care can be developed which would result in closer working with community services and development of a role for a community geriatrician which is focussed on reducing avoidable admissions to hospital. SFT is preparing to develop workstreams which would help support an application to become a provider of community services when the current contract for Wiltshire is put out to tender (this is anticipated in 2013/14 with the contract taking effect during 2015). Specialist commissioning SFT has a high level of specialist services for a medium sized DGH. Specialist services account for around £26m (which is over 14%). The changes to the way that these services are commissioned presents a potential level of risk to the Trust, the impact of which is currently unclear. SFT sits on the southern boundary of the South West specialist commissioning area (which is centred in Bristol), although the Trust has closer clinical and geographical links with the South Central specialist commissioning group. Ongoing discussions around additional services which may fall to specialist commissioners increase the risks to the Trust if a regional approach is to be adopted. In addition to the Trust’s specialist services, military healthcare will also be commissioned by specialist commissioners. Activity profile In providing the figures that are submitted in this document, the following assumptions have been made:

• 2012-13 activity data was used to determine activity by specialty, CCG, HRG and patient type. • The expected population change was applied to the activity data, using ONS estimates. • Conservative estimates for planned increases in market share for electives and daycases were

incorporated into the model. • A planned reduction in the follow up to new rates have been applied to outpatient activity, where

improvement work is anticipated. This has resulted in the following projections of future activity:


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2012-13 2013-14 2014-15 2015-16

A&E Attendances 42,925 43,105 43,384 43,607

Outpatients 2012/13 2013/14 2014/15 2015/16 New 66,066 66,066 65,264 64,264 Follow Up 140,591 137,986 137,043 136,243 Procedures 35,658 35,658 35,815 35,970 Total Outpatients 242,315 239,710 238,122 236,477

Admitted Patient Care 2012/13 2013/14 2014/15 2015/16 Day Attenders 6,446 6,446 6,446 6,446 Daycases 18,319 18,319 18,520 18,720 Elective 6,314 6,314 6,280 6,250 Non-Elective 25,242 25,242 25,190 25,140 Grand Total 56,321 56,321 56,436 56,556

Diversifying income SFT is exploring additional sources from where income can be generated from outside of NHS income streams. Current suggestions include:

• Increasing the amount of private patient activity performed at the Trust • Investing in and expanding the provision of fertility treatments • Bidding for commercial contracts to increase the amount of activity through the Trust’s laundry • Establishing a partnership to develop anatomical models which can be sold commercially • Rebranding and relaunch of moisturising cream which the trust has developed • Sharing success of a volunteer programme run by the clinical psychology team by offering to

support organisations to develop similar programmes • Exploring the possibility of providing mortuary capacity on a commercial basis and providing

autopsy service for a wider geographical area • Increasing the amount and range of medical equipment, for example orthotics or physiotherapy

aids which can be purchased from the Trust • Increasing income from the products produced by the Wessex Rehabilitation service

2.8. Collaboration, Integration, Shifting Settings of Care and Patient Choice SFT’s strategic plan sets the challenge for the organisation of working more collaboratively to refine and develop services to make them more effective and responsive. As such the Trust’s strategy sets targets around reducing the rate of non-elective admissions, for example as a result of exacerbation of chronic diseases. The Trust will be working especially with Wiltshire CCG to realise these aims in the following areas:

• Developing a primary care presence in ED such that patients are triaged promptly and directed to the clinician most able to take forward their care

• Developing more care pathways which will see patients treated on an ambulatory care basis • Developing a community geriatrician model where expert input is provided in the community to

avoid patients’ condition escalating and requiring admission


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• SFT will be trialling telehealth to determine whether the use of technology can support patients at home for longer and so reducing admissions which result from a deterioration of a chronic condition.

• The use of wound telemedicine will be expanded as this has been shown to motivate patients, improve compliance with treatment and improve leg ulcer healing rates

• The Trust is working with the CCG and Social Services to explore the possibility of developing an intermediate model. Accommodation has been identified within the SFT site where patients who do not require acute hospital care, but are unable to stay at home could be admitted under the care of their GP.

• In terms of the development of partnerships and collaborations with other providers the Trust is

o Continuing to discuss possibilities of collaborating with other providers to develop a more efficient way of providing pathology services

o Expanding the plastic surgery input it provides into the Trauma Centre in Southampton. o Investigating the benefits of acquiring University Hospital status

3. Approach taken to quality

3.1. Overview The Trust has a Quality Strategy with clear priorities as set out in the Quality Account. The Quality Strategy and Quality Account seek to ensure that high quality care is at the centre of everything we do for all our patients and to confirm that the direction of travel is both documented and measurable. Over the next three year period the five Quality Strategy objectives and subsequent Quality Account priorities are set out as follows:

1. Ensuring compliance with regulatory frameworks 2. Working in partnership 3. Delivering effective care 4. Delivering safer care 5. Improving patient experience

The Trust delivers the strategy through a robust quality governance framework and gives assurance to the Board that it is compliant with essential levels of quality and safety through its reporting schedule and is continuously striving for quality improvement. The Board is made aware of potential risks to quality via the Assurance Framework and risk register. SFT had an unannounced inspection by the CQC in February 2013. Five of the seven essential safety standards were met. Minor concerns were raised around the levels of staffing and the security of patient records at ward level. Action plans have been developed and submitted to the CQC who have confirmed that they will revisit the Trust in the autumn three months after action plans have been completed. This visit will determine whether these concerns have been adequately addressed and whether the concerns will be lifted. The key quality risks inherent in the plan and how these will be managed Use of the Salisbury Organisational Trigger Tool (SOTT) enables clinical services and management teams to identify risks to the delivery of high quality care and to take prompt action to mitigate them. Using this method, the following key risks have been identified:

• Failure to achieve targets around C Difficile and MRSA. Additional cleaning standards were introduced to ensure that high levels of cleanliness are maintained. Regular hand washing


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initiatives and cleanliness audits are activities, which ensure that the prevention and control of infection remains a high priority, led by the Director of Nursing

• Reporting a mortality rate outside the expected range – this risk is mitigated by the Mortality Steering Group who ensure that risks identified from all sources (which include Dr. Foster, CQC profile, NHS Clinical Indicators) are investigated. The Trust has also established a multidisciplinary team (which includes GP’s) who review deaths to ensure any “avoidable deaths” are identified and learning shared. This priority is led by the Medical Director and the Trust has an established target that its mortality rate should remain within expected levels.

• Inability to recruit and retain appropriately skilled staff - a campaign is to be launched to recruit for all nursing vacancies which will include recruitment from overseas. A series of workforce indicators will be monitored at operational and board level giving details on vacancies, sickness, turnover and agency usage. A skill mix review aims to ensure that the establishment of staff matches the needs of the service and dependency of patients. A forecasting model is being developed which will allow recruitment activity to match anticipated vacancies.

• CT scanner – SFT currently has one CT scanner which leaves the Trust vulnerable if it is out of action. A business case has been approved to procure a second scanner which will be operational in 2014. A fundraising campaign is raising the capital costs.

• The Trust needs to communicate and deliver its response to the Francis report to provide assurance to staff, patients and the local community that it is addressing the issues raised by the Francis report. This will be done at the Annual General Meeting in September. An event celebrating the high quality work of front line clinical staff has been held and was well attended. Following a skill mix review, a successful recruitment campaign in Portugal resulted in the appointment of 45 registered nurses and this will support directorates to deliver real quality improvements by reducing the use of agency staff. National guidance will be used as a framework to review how complaints and concerns are handled at a local level.

3.2. An overview of how the Board derives assurance on the quality of its services and safeguards patient safety.

The Assurance Framework is the main tool which provides the Trust Board with a vehicle for satisfying itself that its responsibilities are being discharged effectively. It identifies through assurance where aspects of service delivery are being met to satisfy internal and external requirements. In turn it will inform the Board where the delivery of principal objectives are at risk due to a gap in control and/or assurance, allowing the organisation to respond rapidly. The whole Assurance Framework is reviewed bi-annually by the Trust Board. The Framework identifies the principal risks facing the Trust and informs the Trust Board how each of these risks is being managed and monitored effectively. Each principal risk has an identified local risk manager who is responsible for managing and reporting on the overall risk. An assurance committee is also identified to assure the Trust Board that each principal risk is being monitored, gaps in controls identified and processes put into place to minimise the risk to the organisation. The Assurance Framework has identified strategic risks around the following areas:

• Improving safety • Service improvement • Patient and public involvement • Customer care • Staff wellbeing • Finance

The designated assurance committees of the Trust Board are the Clinical Governance Committee (clinical risk), the Workforce Committee (including health and safety), Joint Board of Directors


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(organisational risk including information technology) and the Finance Committee (Financial Risk). The Audit Committee monitors the Assurance Framework process overall on a biannual basis. It is the responsibility of the assurance committees to report to the Trust Board on a quarterly basis any new risks identified, gaps in assurance/control, as well as positive assurance on an exception basis. If a significant risk to the Trust’s service delivery or gap in assurance/control is identified, then this is reported immediately via the Executive. Each Department carries out risk assessments which inform the Assurance Framework. Each Directorate maintains a comprehensive risk register, which is formally reviewed at three monthly intervals through the directorate meetings with the Executive Team. These meetings will also identify those departmental risks which pose a corporate threat and so require inclusion on the Trust Risk Register.

3.3. How The Trust Board Has Considered The Impact Of Quality On Patient Care High quality care is the principal priority for the Trust and the Board is committed to improving quality through a ‘whole organisation approach’. The Quality Indicator report, which goes monthly to the Trust Board, captures key information required by the Board to satisfy itself that it is discharging its responsibilities. To this end the metrics within the Quality Indicator report include (but are not limited to) health care associated infection (HCAI) rates, serious incidents, never events, mortality rates and HSMR/SHMI, time to theatre for a fractured neck of femur, real time feedback key question results, mixed sex accommodation breaches, pressure ulcer rates and falls resulting in harm. The Director of Nursing and Medical Director are responsible for ensuring that the quality indicator report is fit for purpose and that the measures contained reflect the Trust priorities. The Trust Board is briefed in private on all serious incidents, clinical reviews and never events. All such incidents are formally reviewed by an appropriately constituted review panel – the Board is informed about the learning from these reviews and the reports themselves are signed off by the CEO, MD and DoN at a formal exit meeting. The Clinical Governance Committee (CGC) provides the Trust Board with the assurance that high quality care is being provided to patients. At each CGC meeting, one of the clinical directorates presents the latest data for the services within that directorate highlighting trends and the actions they are taking to ensure quality of care improves. This gives the CGC genuine assurance at a Directorate level of the constant focus on the quality of care delivered. A patient experience story is heard at every Clinical Governance Committee meeting. These experiences may have come from complaints, incidents or from service improvement projects. The quality indicators and patients’ experiences ensure that the Trust keeps focused on the things that are important to patients. Patients and staff are also involved in service improvement events. A good example of this can be seen in two medical wards who have used the learning from the Kings Fund Point of Care programme to improve processes of care and staff-patient interactions. The Trust uses weekly executive led safety and quality walk rounds which enable staff and patients to talk directly with members of the Trust Board (both executives and non-executives) and raise any quality or safety concerns they may have. The Trust has continued to use a ‘trigger tool’ for each service, which is a method that enables teams to self assess against key quality performance criteria to identify risks to delivery of quality and focus on actions for improvement. The Trust also uses clinical audit results, patient feedback, national survey results and information from complaints and safety reports. These show where improvement is needed and all wards develop action plans to respond to feedback from patients.


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Over the past year, the Trust has continued to make progress in many areas that affect the quality of care that is given to patients, their families and visitors. This is reflected in a number of positive improvements. These include better access to specialist advice for GPs, to avoid patients being unnecessarily admitted to hospital, more training for staff to help care for people with dementia and improved use of patients being cared for on the Liverpool Care Pathway at the end of their life. The Trust has also continued to maintain high standards of cleanliness (as evidenced by the PEAT reviews) and reduce the number of grade 3 and 4 pressure ulcers. With the publication of the Francis Report in February 2013, the Board is taking a number of actions to assure an outstanding patient experience and implementation of relevant recommendations. The Medical Director and Director of Nursing presented a summary of the report at the Board in March 2013 at which a gap analysis and action plan against the recommendations was commissioned. Key areas such as workforce performance indicators will be introduced and reported to the Board quarterly. Lessons from the inquiry are being shared widely with staff through Chief Executive, Directorate briefings and the Clinical Governance half day in May 13 will be led by the Director of Nursing and devoted to patient experience.

3.4. How The Trust Board Has Considered Patient Safety As A Priority One of the identified priorities in the quality account is to “continue to keep patients safe during their stay in hospital”. The safety of patients is a key aim in the Trust’s quality improvement work. SFT has been actively engaged in a patient safety programme to reduce levels of harm to patients whilst they are in hospital. Examples of how this is measured include informing the Board about pressure ulcer rates, infection rates, cardiac arrest calls and the number of patients who fall whilst they are in hospital. This compliments the monitoring of national priorities through the Safety Thermometer (including measures of incidence of pressure ulcers, falls, urinary infections from catheters, and venous thromboembolus). The prevention and control of infection is always a high priority. Where incidents relating to patient safety occur, an immediate and proportionate response is initiated and an action plan agreed. The level of response and investigation is guided by the risk management policies which have been shown to be clear, effective and used in every day practice through the NHSLA level 2 assessment process. Clinical Reviews and Serious Incident Inquiries form part of this learning framework with outcomes reported to the Trust Board. This process provides the Trust Board with an assurance that a thorough investigation has been performed and that learning will result in improved future performance.

4. Clinical Strategy

4.1. Overview The essence of SFT’s strategic direction over the next five years is that it will provide a comprehensive range of high quality local services, enhanced by developing its specialist services, which patients choose to access for their responsiveness and effectiveness and reputation. It is vitally important that the local population have access to a comprehensive range of core services to meet the vast majority of their health needs:

• Emergency care – Emergency Department, acute assessment, inpatient surgical, medical and trauma beds, acute paediatrics and intensive care

• Planned surgical and medical care – comprising inpatient and ambulatory services • Clinical investigations – the main radiological modalities, endoscopy, pathology services

required to support acute care provision. • Maternity services, including NICU. • Community facing services


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As the only acute provider physically located within the county, we will look to grow our catchment population as a result of patient choice. For SFT to be the provider of choice for local services it is essential that we offer services with a high quality of care, a strong customer focus which as a result deserve a reputation for excellence. In turn this will ensure that sufficient activity is carried out within the hospital to maintain skills and safeguard the quality of training for health professionals of the future. The Trust’s specialist services are fundamental to our ability to provide the resilience to maintain the full range of services at SFT whilst providing ground-breaking care in their own right. We will develop these services further, informed by leading edge research, to ensure that they have a national, if not international, reputation.

4.2. Service Line Management Strategy – Local Services Peripheral clinics Increasing the Trust’s referral base is a key element of the strategic aim around Choice and its plan to increase market share. SFT will work to expand the boundaries of the catchment area and has prioritised 3 geographical areas – Warminster & Westbury (to the north west), Devizes (to the north) and Ringwood (to the south). The Trust is working with GP’s and patient groups in these areas to enable peripheral clinics to be provided which support referring clinicians and provide care closer to home for the local population. The Trust invested in equipment and has also been supported by local groups (such as League of Friends, Hope for Tomorrow) which enables more treatments to be carried out in peripheral locations. The Trust is looking to expand the numbers of procedures which can be performed in peripheral locations (vascular surgery, infertility and plastic surgery). Specialities where peripheral activity will be increased over the next year include orthopaedics, rheumatology, ophthalmology, infertility and, potentially, maternity. Recent consultant appointments in these specialities have supported this initiative. 23 hour surgery & plastics trauma in DSU Proposals have been developed to expand the opening hours of the Day Surgery Unit to incorporate a 12 bedded ward equipped to accommodate patients requiring a stay of up to 23 hours. This additional capacity will allow more flexibility at times of increased pressure on inpatient beds. Second CT Scanner In support of the principle of ensuring emergency services are robustly provided, the Trust is proposing to invest in a second CT scanner so that an urgent CT scan can always be provided. The additional scanner will also support clinical services to provide more complex procedures, for example in cardiology and colorectal surgery. A business case has been approved for a second CT scanner to be procured. The Trust’s charity is launching a campaign to raise the capital funds and the NHS will provide the revenue costs. Until the funds are in place, a mobile scanner will visit the site on a regular, planned basis Increased ICU provision As non-elective activity continues to rise and more complex surgical procedures are performed, the demands on the Trust’s intensive care beds (ICU) have risen. Increasing capacity in this area will provide the Trust with greater flexibility when scheduling elective surgical procedures. The cost of increasing capacity can be balanced against the requirement to provide ICU beds for non-elective activity and the ability to offer complex surgical procedures.


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Best practice tariffs The Trust will ensure that patients are cared for in accordance with guidance around best practice tariffs. This ensures that high quality patient care is delivered and that the Trust is remunerated appropriately. Cancer services SFT will work with partners to improve public awareness and the early diagnosis of cancer. As a provider trust, SFT is required to achieve all national requirements relating to the timely collection and reporting of staging information. The Trusts target for compliance is 70%. The Trust is required to demonstrate the ability as a provider to manage cancer as a long term condition and adopt improvements demonstrated by the National Cancer Survivorship Initiative. The Trust will also continue to demonstrate support for cancer research by ensuring that research remains a core activity to which the Trust is committed. Collaboration with Primary Care The Trust is working with GP’s from the local CCG to develop agreed integrated care pathways which will improve the quality of referrals and support clinicians to discharge patients from hospital care which is in line with requests from local GP’s. Reducing follow up activity will increase capacity to enable “SOS” appointments to be offered to patients when they need to be seen, for example during an acute flare up of a chronic condition. Rapid access clinics Rapid Access Care of the Elderly (RACE) clinics are being piloted to determine whether fast access to a senior decision maker can help reduce avoidable hospital admissions amongst elderly patients. GP’s and the Emergency Department (ED) are able to refer patients to the RACE clinics. Acute care at home Work is ongoing to reduce length of stay. One initiative involves SFT staff providing acute care to patients within their own homes. An example of this is the administration of intravenous antibiotics where patients have traditionally needed to come to hospital for this treatment. Pilot schemes are trialled prior to business cases being developed to ensure that proposals are robust and effective. SFT is, in some specialities, providing an acute outreach service where staff are trained to provide a bespoke holistic package of care to patients in their own homes. An example of this is where physiotherapists visit patients and assess their mobility, ability to care for themselves and check operative wounds following discharge from hospital after joint replacement surgery on an enhanced recovery pathway. Emergency flow The Trust will continue work to improve the flow of patients through the organisation throughout the week which will help to reduce length of stay. Achievement of this objective is dependent on increasing presence of key personnel (e.g. consultants, therapists, pharmacists, social care personnel) at weekends to ensure that patients can be discharged 7 days a week if this is appropriate. The Trust will work increasingly with networks (for example TIA, stroke, vascular). Social care teams have been located with the Trust’s discharge team to improve communication and help reduce unnecessary delays when planning complex discharges. Mental health liaison The Trust is in advance stages of negotiations with Avon and Wiltshire Partnership (AWP) to provide a mental health liaison service for the Trust from September. Focusing on ED and the inpatient wards, this much needed development has been supported by NHS Wiltshire and will see patients with mental health needs reviewed more quickly and able to access support far quicker than is currently the case. This will help greatly with flow through the hospital for these patients as well as providing the specialist care the patients require. Capacity Planning Tool A capacity planning tool is being developed to ensure that robust information is available to determine current and future bed capacity required and to allow sensitivity analyses to assess the impact of service developments on bed requirements.


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Repatriate cardiology activity SFT has invested in cardiology which has enabled the Trust to increase capacity for interventional work. This will allow patients to be treated more locally rather than having to travel to Bournemouth or Southampton for their procedures. SFT will be setting up a complex device management service during the coming year and are in discussions with commissioners regarding the creation of a more local primary angioplasty service. High quality facilities The quality of facilities is known to be a factor influencing patient choice. SFT has been successful in securing funds to improve facilities for expectant mothers and their families in the labour suite and this work is currently underway. A second stage bid was submitted at the end of April to seek to secure £800k of capital funds to improve the ward environment from which care for patients with dementia is provided, focusing in the in the first instance on Redlynch. The lessons from this scheme will then be applied to the other Phase 1 wards, particularly the ones where elderly care patients are cared for. The Trust will be renewing its five year estates strategy during 2013. High quality environment During the coming year SFT will introduce the new Patient Led Assessment of the Care Environment (PLACE) process to ensure the Trust’s facilities across the four domains (cleanliness, food, wellbeing/privacy and dignity) and facilities management are of a high quality. Site Security The Trust will continue recent security initiatives to enhance further the safety of patients and visitors and of our staff.

4.3. Service Line Management Strategy – Specialist Services SFT’s strategy is to develop its specialist services and determine their position within the new commissioning environment. Opportunities to work closely with the military (plastic surgery and rehabilitation services) will be pursued. Promotion of non NHS services will be another area of focus as CCG’s tighten referral criteria. The appointment of a rehabilitation consultant enables multidisciplinary programmes of care to be promoted and SFT to be positioned as a centre of excellence for rehabilitation services, particularly as the Trust’s Wessex Rehabilitation services link closely with the Duke of Cornwall Spinal Treatment Centre and the Wessex Trauma Network. Investment is being made in the Spinal Unit to increase the capacity for up to six patients requiring high care (mechanical ventilation) which will mean an earlier transfer to the specialist unit from local units. SFT is working closely with Southampton University Hospitals (UHS) to provide plastic surgery input into the major trauma centre. SFT plans to develop the service provided at UHS which will increase activity for the Trust. Working with the local CCGs, pathways are being developed for lower back pain which allows the programme offered by the Wessex Rehabilitation service to be positioned appropriately. Raising the profile of rehabilitation services The advent of major trauma networks has helped to raise the profile of rehabilitation services both locally and nationally. The Wessex Rehabilitation team plays an active role in the regional trauma and rehabilitation networks providing care to patients from a wide geographic catchment area. A directory of services has been developed for trauma and rehabilitation services. Opportunities exist for SFT to become involved at a national level as work progresses to develop national tariffs for rehabilitation services. Challenges exist as local commissioners do not currently fund rehabilitation programmes unless this is done through exceptions funding agreed on a named patient basis. By working to raise the profile of


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the service of the Wessex Rehabilitation Unit, the Trust will look to generate activity in this area, increase usage of this facility and improve outcomes for patients who suffer chronic pain or disability. Pelvic floor surgery The Trust’s colorectal and urology teams are working together to provide complex pelvic floor surgery for patients with incontinence. Genetics The Trust’s genetics service is to carry out next generation sequencing. This will enable the service to provide specialist commissioners with more rapid testing for a wider range of rare disorders. This will attract contracts from a wide geographic area, enabling SFT to secure its position as a regional provider of specialist genetic services.

4.4. Clinical Workforce Strategy Medical Staff The Trust is conducting clinical service reviews to help establish a shared vision of the shape of the medical workforce of the future, and inform the planning of the wider medical workforce. We are reviewing risk areas in future service provision and supporting workforce design and planning to mitigate threats, including understanding the implications of trainee reductions on the sustainability of OOH cover and developing plans to maintain services. By the end of 2014 60% of senior doctors will have undergone revalidation. Nursing Staff In 2013/14 and beyond, the Trust will be considering the implications of the Francis recommendations impact on nursing workforce and implementing them as necessary. We are seeking to understand our current workforce better, by scoping clinical requirements for Bands 6 and 7, carrying out a skills gap analysis for all nurses and planning development activities, completing a ward skill mix review and implementation of the findings. The Trust is currently experiencing difficulties in recruiting band five staff nurses, leading to an over-reliance on bank and agency staff. This is due to a national shortage of newly qualified Nurses. In order to address this, a recruitment trip to Portugal to recruit 45 newly qualified nurses has just taken place. In terms of designing the future workforce, we will be further developing Band 4 Assistant Practitioner roles through extended practice. We will be continuing to explore roles for senior nurses in junior medical staff service provision. Clinical Scientists We are looking to implement and maintain high quality training programmes for all health care scientists, raising the awareness and profile of health care scientists (HCS) in this trust and ensuring that scientists have a voice at Trust board level. In 2013/14 we will be looking at training provision for Assistants and Associate practitioners and continuing to explore opportunities for use of apprenticeship schemes and increasing the PTP programmes across many more health care science areas. We will develop higher specialist scientific training programmes (HSST) in areas such as engineering and genetics and take steps to improve HCS leadership and management development. We will aim to ensure that our work based trainers and mentors have adequate support to be able to carry out their roles.


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Other Staff Groups We will be further developing workforce metrics, including separate clinical and non-clinical staff metrics to help increase workforce productivity and improve unit labour costs, with greater role flexibility and extended practice. We have planned to implement trainee nurse assistant apprenticeships, and are looking at exploring cross-Trust bank sharing opportunities, developing a Trust strategy on 7-day working and re-launch the Salisbury Organisational Trigger Tool to enhance workforce assurance capability. We will also continue to look at how we effectively utilise the volunteer workforce which is a valuable additional resource for the organisation to enable the paid workforce to be focussed on particular aspects of service requirements. The impact of the Workforce Strategy on costs (short-term and long-term); The Trust has a £9m savings and income generation target for 2013/14. It is estimated that at least £5m of this will need to be met through changes to workforce, both in terms of increased productivity, skill mix, actual workforce numbers and reduction in agency usage. Any changes will maintain patient safety and quality of the patient experience as an absolute priority. This will be monitored by performing quality impact assessments as a method of assurance. Findings of benchmarking or other assessment Overall in 2012/13 the Trust performed well in comparison to other local Trusts against a range of workforce indicators, with comparatively low sickness and staff turnover rates. Staff survey results were good, showing low numbers of staff experiencing bullying, harassment and abuse, and high levels of staff engagement. Average earnings were lower than average, as were numbers of staff receiving appraisals. Workforce productivity expressed as a cost weighted output / cost weighted workforce capacity was near average nationally, although below average for local Trusts. Against the DH Workforce Assurance Tool, the Trust showed green overall, with a score of 0.45. Of 61 specifically workforce related areas, 3 were rated as red, and one was amber. The other 58 were rated as green. Red areas were births to midwives ratio, percentage of staff appraised, and percentage of staff well appraised. Action plans are in place to improve these scores. The amber area was nurse to bed ratio, which with a score of -0.18, was only very slightly below the level required for green. A nurse recruitment drive is underway to help address this. The staff section of the Trust’s strategy has clear targets on a range of key workforce indicators building on recent performance and use of benchmarking information such as this.

4.5. Clinical Sustainability SFT is currently in discussions with commissioners, GP’s and local providers regarding the future provision of complex vascular surgery. Currently the Trust is in a clinical network with Bournemouth and Dorchester hospitals, with out of hours on-call responsibility rotating between surgeons at the three sites. It is extremely unlikely that this will be sustainable in the medium term and, therefore, SFT is working to develop proposals to ensure that there remains a vascular presence on site to support the Trust’s services and to ensure that the general surgical on-call rota is not adversely affected. Commissioners will need to consult on the impact on the local population of these changes. The implementation of the Improving Outcomes Guidance (IOG) for cancer services has impacted some of the Trust’s surgical services with some primary surgery for cancer having transferred to specialist centres over the last 10 years. Patients are still diagnosed at Salisbury, often the surgery is performed by a Salisbury surgeon at the specialist centre and the patients receive their follow up at Salisbury. There remain a number of tumour sites where the numbers performed by SFT clinicians may be insufficient for surgical treatments to remain at SFT much beyond the life of this plan.


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Under the leadership of the Medical Director, a series of clinical reviews of individual specialties or services are being carried out which will include an analysis of the current and future clinical issues faced in the delivery of these services.

5. Productivity & Efficiency

5.1. Overview The Programme Management Office (PMO) was established in September 2012 bringing together programme management, project management and service improvement expertise. The Office reports to the Chief Operating Officer (COO) and has been working with the Directorates and executives to identify a 3 year rolling CIP programme. The PMO has produced an annual work plan for 2013/14 which includes all CIP schemes identified across the Trust and will ensure that the correct documentation and processes are followed to deliver sustainable efficiencies. All schemes are assessed for delivery, quality and clinical risk and each scheme will be discussed with the Medical and Nursing Directors to establish those schemes which require detailed quality impact assessments

5.2. CIP Profile The CIP schemes are categorised into the following workstreams:

• Workforce • Non pay & procurement • Income • Pathway redesign

During 2013/14 the main transformational / service redesign project identified relates to the entire administrative processes from referral to discharge of patients attending outpatient services. This will be driven by the PMO and achieved in a phased approach using service improvement methodology and significant clinician involvement to identify sustainable and efficient standardisation of processes. Other schemes that will follow a similar process include:

• Procurement / Non Pay - reduction in the cost of maintenance contracts through switching suppliers and using managed services and reducing the cost of consumables

• Providing safe and appropriate staffing levels without the use of agency staff. This will be achieved by ensuring appropriate enablers are in place prior to eliminating the use of agencies to provide staff to cover short and long term workforce gaps

• Workforce reviews – a programme of service by service reviews to determine the potential for reducing expenditure on pay through a range of different initiatives

• Bed capacity modeling – to promote reductions in length of stay (LOS) and providing opportunities to improve bed utilisation

• Theatre utilisation – following the implementation of the Theatre Management System – this project is concerned with improving theatre list utilisation and a reduction in additional activity payments to allow maximise throughput

• Improvement in the capture of clinical data through education, training and improved policies / checklists

• Market share income growth in specialty areas including orthopaedics, rheumatology and relating to activity provided to the military

• Electronic communication – a project has been started to increase the amount of information which is shared between providers electronically is increased. The new PACS/RIS system will support the electronic transfer of images between clinicians. A project to allow clinical


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correspondence (including GP referrals) to be shared electronically has been started and ultimately will see patient letters and results transmitted in the same way

• External support has been secured to assist the Trust in securing additional savings from its drug budgets over the next three years.

5.3. CIP Enablers The requirement for enabling investment in infrastructure (external support, IT, project delivery resources, etc.)

• The engagement of clinicians is embedded into the directorate structure and management. Following the CIP plan submission to the CIP Steering Group, the Clinical Directors attended an additional meeting to discuss the Directorate CIP’s with the Executive Directors. This meeting identified further opportunities which should be explored

• The Clinical Directors have presented the directorates clinical strategies to the Trust Board • Clinicians are also engaged throughout the life of a CIP project with representation on either

project teams or project boards. The number and background specialty of clinicians involved is dependent on the size and theme of the CIP scheme

• Introduction of Lead Clinician workshops and forums with external support (e.g. from NHS Elect) • An important enabler throughout the time of this plan will be the Trust’s Informatics strategy

which describes how the Trust will implement an electronic patient record (EPR) and, in so doing, move towards becoming a paperless organization.

5.4. Quality Impact of CIP’s The PMO has produced an annual work plan for 2013/14 which includes all CIP schemes identified across the Trust and will ensure that the correct documentation / processes are followed to deliver sustainable efficiencies. All schemes are assesses for delivery, and clinical risk, and each scheme will be discussed with the Medical & Nursing Directors to establish which schemes require quality impact assessments (QIA). Once identified the Directorates will undertake the QIA and submit complete assessments to the Joint Board of Directors to establish which schemes can proceed. The measures of quality used to inform the assurance and how the Trust monitors the quality impact of CIPs on an on-going basis includes:

• Clinical quality dashboard monitoring • Ongoing assessment of services using the Salisbury Organisational Trigger tool (an evidence

based tool which is used to review quality at a department or ward level). This tool acts as an early warning system to flag issues that may impact on patient care

• Reporting through existing Senior Management and Executive Director meetings where quality, finance, HR & performance are monitored

6. Financial Investment & Strategy

6.1. An assessment of the Trust’s current financial position Salisbury NHS Foundation Trust achieved a financial surplus for 2012/13 of £1.6m, which was greater than 2011/12 and exceeded that shown in its Annual Plan. The Trust’s financial goals for the three year period are summarised in the table below:


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Key Indicators 2012/13 2013/14 2014/15 2015/16 Revenue Surplus £m 1.6 1.8 1.9 2.1 EBITDA for FRR £m 14.7 15.4 15.6 16.5 EBITDA as % of income % 8.1 8.4 8.6 9.2 FRR 3 3 3 3 CIP & income generation £m 7.6 9.2 8.2 8.2 Identified £m 7.6 6.6 1.0 0 Unidentified £m 2.6 7.2 8.2 % of Operating % 4.4 4.1 4.7 4.5 Tariff reductions % -1.1 -1.1 -1.1 Inflation Pay % 1 2 2 Other % 3 2.5 2.5 Capital expenditure £m 7.4 12.4 9.0 10.0 Cash at year end £m 17.1 14.3 15.8 17.5

The Trust regularly reviews the economy, efficiency, and effectiveness of the use of resources through: benchmarking, reference costs, regular meetings between the Directorates and Executive Directors, and assessing performance against plans. Investments are determined against detailed business plans and outcomes are reviewed against those plans. The Trust Board, through its sub-committee the Finance Committee, reviews performance against savings plans and the delivery of efficient services within budget each month. A Programme Steering Group (PSG) supported by a Programme Management Office has been established to drive forward savings across the Trust. Membership of the PSG comprises the Executive Directors, Directorate Managers and other senior staff within the organisation. The PSG membership includes both the Medical Director and the Director of Nursing to ensure that the quality impact of cost savings is fully considered. The Group has assisted in achieving the savings target for 2012/13, has reviewed the emerging plans for 2013/14 and will continue to review those plans in the light of performance in year. The Trust has been successful in achieving cost savings through various service improvement projects, which assists the Trust to continue to deliver efficiency and effectiveness whilst enhancing the patient experience. Procurement of goods and services is undertaken through professional procurement staff and through working with neighbouring organisations within a procurement confederation. The cost of goods is regularly benchmarked and as a result the Trust has continued to deliver significant cost savings as a result of excellent procurement. Activity levels are assumed to remain broadly level with demographic growth being offset by QIPP reductions. No assumption has been made about the level of growth in the local military population as information is not currently available on which to plan realistically. However there will be close attention to this over the next year so that any necessary changes in capacity can be addressed in good time. The intention of the Trust is also to be active in any future tender opportunities although no assumptions have been made about the success of these. The start point of the plan is 2012/13 outturn actual expenditure as income has been commissioned in all cases based on last year’s outturn.


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6.2. Key financial priorities and investments and link to the Trust’s overall strategy Key financial strategy elements for the three years ahead are:

• Minimum 1% surplus per annum to support capital expenditure • FRR of 3 or greater (or equivalent on new Monitor system) • Maintain sound liquidity (30 days payments) • Working capital to remain positive • Capital expenditure at least equivalent to depreciation • New borrowing limited to short term invest to save schemes • Remain in the upper quartile for efficiency of acute Trusts • Optimise commercial opportunities to support savings plans

6.3. Key risks to achieving the financial strategy and mitigations The main risks to delivery of the financial strategy can be divided into internal and external risks. Internal risks include the non-delivery of CIP’s given the continuing high levels of savings demanded not only by the Trust but the NHS as a whole but also because SFT is a relatively efficient Trust based on Reference Costs and this makes targeting savings more difficult. However the new PMO will assist in ensuring that the focus on delivery of CIPs is owned across the Trust and the solutions can be based on improvements to the methods of service delivery which can be more readily owned by operational and clinical departments. Externally should there be disagreements between commissioners following the significant changes to commissioner responsibilities this year the Trust may find it difficult to recover all the money owed to it for activity delivered. In order to mitigate this, the Trust has reached agreement with its main commissioner and the specialist team that in the event of a disagreement between them that we will continue to bill and be paid the contracted amounts at least in the short term. Of particular concern is the impact of specialist commissioning and the national specifications of service which may cause enormous difficulties locally. This area of work is also our second largest commissioned activity and therefore very important in the recovery of overheads. In the event that activity reduces based on 2012/13 the Trust will need to reduce its costs accordingly but the Trust considers that it has allowed sufficient contingency to deal with this in the short term, as described in the risks and mitigations section of Appendix 1.

Strategic Plan 2013 – 16 (Appendix 1)

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Appendix 1: Financial commentary The attached financial plan shows a risk rating of 3 throughout the three years with a surplus of £1.8m in 2013/14, £1.9m in 2014.15 and £2.1m in 2015/16. Income The Trust will have contracts with Wiltshire, Dorset and Hampshire CCGs and their associates. Also there will be important contracts for specialist, military, and dental/oral work. The contracts will be based on PBR and reflect the outturn positions from 2012/13 as the base position for 2013/14. The contracts will contain specific QIPP arrangements although the risks for these schemes sit substantially with the commissioners, as they mainly include the commissioners introducing demand management schemes. The Trust has agreed to work collaboratively with the CCGs in the introduction of any demand management arrangements. The consequences of QIPP schemes of £1.5m being delivered in 2013/14 has been fully allowed for in the plans for 2013/14 and additional schemes have been assumed for 2014/15 (£1m) and 2015/16 (£1m) and included within the plan. There have been large swings in value between contracts in 2013/14 over 2012/13 to reflect the significant shift of resources into Specialist Commissioning although overall the contract values in total are slightly above those for 2012/13 even after allowing for QIPP and the effects of the 2013/14 tariff. The government has recently announced changes to the disbursement of military personnel within the UK and Europe and the consequence of this change is an increase in population is expected in South Wiltshire. The consequence of this change is likely to be an increase in the uptake of hospital services at Salisbury and so we are currently evaluating the likely impact. At this stage information about the change is inadequate to incorporate in the plan. It is expected that when the detailed appraisal has been completed there will be a financial benefit to the Trust and there will need to be some increase in capacity, for example in maternity services. It is worth reflecting that whilst the negotiation of the 2013/14 contracts has been robust and challenging, the mature and consistent approach adopted by each of the CCG’s gives cause for optimism that the future challenges to be faced by the NHS locally will be dealt with in a planned manner with open communication. Strategic Developments No significant developments have been included within the plan given the significant change in commissioning arrangements, and we wait to see whether the formation of CCGs will impact on our ability to develop new services quickly. The specialist commissioners are though considering proposals for an extension to capacity within the Spinal Injuries Unit, however it is unlikely that a rapid decision will be reached on this given the major changes happening within Specialist Commissioning. Section 4 of the main document sets out the ongoing service changes which the Trust is planning to undertake. Transactions There are none to report nor planned.


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Workforce The workforce costs include an allowance for incremental drift based on a review of the actual workforce profile and the expected incremental points to be achieved during the year. No reduction has been included in any year of the plan to take account of the impact of this year’s pay settlement given timing of the announcement. Analysis is though being undertaken to estimate the likely impact in future years. Pay inflation has been assumed to be 1% in 2013/14 and 2% in each of 2014/15 and 2015/16. As stated earlier the Trust has reviewed its nursing arrangements in the light of the Francis report and as a consequence has undertaken a major nurse recruitment campaign in Portugal and the likely impact is the recruitment of around 45 staff. The impact of this change along with other nurse recruitment will be to increase nursing staff whole time equivalents by 10 and to reduce the cost of agency by around £500k in 2013/14 and a further £500k in 2014/15 as a result of the Trust being able to fill vacancies which would otherwise have been covered by more expensive agency nurses. An increase in staff costs of £206k has been included within 2013/14 with a further £54k in 2014/15 to reflect the cost of the additional 10 nurses. In addition the Trust has included a provision for the impact of pension legislation changes in 2013/14 of £250k as it is expected that a number of staff not currently in the NHS pension scheme will not exercise the option to leave the scheme having been automatically enrolled, we have assumed that this will impact on around 20% of staff not currently in the NHS scheme. We have currently identified around £3m of CIP’s in respect of workforce and currently have another £500k of workforce savings to find. The workforce CIP targets for 2014/15 and 2015/16 are currently £2.85 and £3.34m respectively. To support the above, the Trust workforce priorities for the next three years fall broadly into two main areas:-

• Increase workforce productivity • Improve further staff satisfaction and development

Workforce Productivity An underlying reduction in headcount through QIPP and CIP plans as shown in the table below is expected to be offset by successfully winning additional service contracts, eg AAA screening, laundry services. However, an increase in workforce productivity is our overall target. Headcount Reduction (Whole Time Equivalent) – Numbers to be completed in accordance with Monitor Finance Template. March 2013 March 2014 March 2015 March 2016

Total worked wte 2,658 2,626 2,571 2,494

Net reduction (10) (32) (55) (77)

Spend forecast £114.6m £113.6m £112.7m £111.2m

Pay CIP - £2.87m £2.85m £3.34m


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This will be achieved through a number of mechanisms:-

• A programme of workforce reviews, both at service and staff group level, eg outpatients. • Optimising skill mix and staff utilisation to match demand and service need, using benchmark

information when available. For example benchmark information from the national Audit Office demonstrated skill mix on some wards needed adjusting, a programme of changes, agreed at Board level has just taken place.

• A reduction in agency usage/spend. • Reducing further sickness absence from the 3.30% absence rate achieved in 2012/2013 to

3.00%. • Seeking opportunities to reduce the total workforce costs through actively working on any local

freedoms in national terms and conditions, and robustly implementing nationally agreed changes to Agenda for Change terms and conditions.

• Continuing with existing mechanisms to challenge recruitment rigorously of every vacancy, supported by a risk assessment process.

• Improving the use of benchmarking and other workforce data to inform decisions. • Continue to use strategies to enable the maximum security of employment, even for displaced

staff, and thereby minimise the need for redundancy costs. Staff Satisfaction and Development Improving further on staff satisfaction and development to ensure a highly engaged, skilled and motivated workforce is the second main priority. In 2013/14 this will be achieved by:-

• Acting on the Trust’s results in the national staff survey, in particular continuing to improve appraisal rates and appraisal quality.

• Monitor and refine the infrastructure developed to ensure robust medical appraisal to support revalidation.

• Continue on a programme of development of new roles to support changes in workforce design such as Assistant Practitioners and Nurse Practitioners particularly in relation to supporting medical roles.

• Review and embed the Trust’s values and beliefs, with a programme of actions to include them in the workings of the Trust.

• Make further progress on the priorities identified from our Equalities Delivery System self assessment.

Risks to implementation Achieving headcount reductions without the use of redundancy is becoming more difficult because natural turnover levels are low, and staff in more specialist roles are more difficult to redeploy; a high staff stability ratio means that the Trust has a high proportion of long serving staff who have high redundancy costs. Headcount and workforce cost is monitored on a monthly basis at a joint meeting of Trust executives and directorate managers. Risk of workforce changes impacting on service provision or quality is an issue the Trust is acutely aware of and takes very seriously. Any workforce change in a clinical area is subject to extensive consultation and requires a quality risk assessment prior to implementation. A service organisational trigger tool that requires a self assessment of such risk is undertaken by services on a regular basis and reported at regular directorate performance management meetings. Any changes to the nursing workforce require Director of Nursing approval


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Non Pay The major non pay pressure over the life of this plan is an increase in CNST premiums. The Trust has been notified of an increase in 2013/14 of £968k and has assumed a further increase of £500k in each of 2014/15 and 2105/16. The Trust is however challenging the quantum of the increase and has been involved in protracted discussions with the CNST particularly challenging the validity of the information they have used to calculate the quantum for the Trust. It is expected that in the near future there will be a meeting involving senior staff from the Trust and the CNST to try to agree a way forward. The Trust has assumed that inflation will fall in the next two years in line with briefings from the Bank of England, however the level of non-pay inflation is still assumed to be 2.5% next year and above 2% the following year. However in the light of previous experience we have also included a non-specific cost pressure of £500k for both 2014/15 and 2015/16 which will mitigate any unexpected cost pressures. Given the low level of drugs inflation in 2012/13 the Trust has assumed slightly lower inflation than previously, 3% this year followed by 2.5% in each of the following two years. The Trust has though assumed that new NICE drug regimens will be introduced during the year and has included a cost pressure of £400k. In addition the Trust has been discussing the use of Avastin with Commissioners which would produce a saving to both the Trust and the Commissioners. The net benefit to the Trust has been included for each of the three years of the plan. Capital Expenditure The capital plan for 2013/14 is £12.360m, £9.039m in 2014/15 and £10.013m in 2015/16. This follows capital expenditure of £7.4m in 2012/13. The 2013/14 plan includes slippage from 2012/13 which it is anticipated will be fully invested in year. The major individual schemes are: improvements to the access to the hospital from the rear car parks £1m, laundry improvements £0.8m and maternity £0.4m. The impact of the continuing slightly higher levels of capital investment is an increase to the depreciation charge shown in the Statement of Comprehensive Income. This charge therefore increased from £8.474 in 2011/12, to £8.496m and is forecast to increase further to £9.329m in 2013/14, £10.066m in 2014/15 and £10.353m in 2015/16. Estates Strategy The SFT estates is divided into three main areas, each of which has a different focus in terms of the Trust’s estates strategy: SDH North is the main acute section of the hospital where the majority of the wards, main theatres, ED and diagnostics are located. Most of SDH North was opened in 1993 and is known as Phase 1, with the PFI Phase 2 build having been commissioned in 2006. The focus for SDH North is on refurbishment of the Phase 1 area, as shown by the intention to improve the ward environments. SDH Central houses the Trust’s maternity services (including NICU), the Spinal Unit, Day Surgery Unit and many ancillary departments. The focus for SDH Central is renovation – in particular the maternity department (despite many recent upgrades) is located in 1940’s buildings which need constant attention and maintenance and can only achieve limited improvements.


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Only a relatively few clinical services are situated on SDH South and this area is earmarked for regeneration. The Trust is currently in preliminary discussions with private bidders regarding potential alternative uses for this land, although the intention is that the Trust will retain the freehold. In order to make backlog costs more meaningful in context of asset management and capital investment decision making, a review of backlog costs at Salisbury District Hospital (the key clinical buildings) has been established and assigned to risk. This follows the best NHS practice guidance document "A risk-based methodology for establishing and managing backlog". There are no areas of High Risk. The two major areas of Significant Risk (SDH North Block and Spinal Unit) are currently being carried out in a rolling programme of replacement of air ventilation ductwork in the Trust’s approved capital programme A number of material schemes will be undertaken during the life of this plan: Springs Entrance development – A £1m development which will see a substantial improvement to how patients access the hospital through a major entrance into the site (the main entrance is the subject of a smaller capital scheme in 2013/14). The Springs Entrance scheme will start in early 2014 as there are important interdependencies with other building projects in that part of the site. The project will be funded from the Trust’s capital. The scheme will improve the environment for patients, will create a new area for the Trust’s customer care service and will offer opportunity for further retail outlets in an area of high footfall. Laundry equipment and building – in order to compete more effectively in the commercial laundry environment, the Trust has decided to establish a stand-alone company 100% owned by the Trust. The company, with loans from the Trust, will be investing in further equipment to reduce manual handling of laundry In order to improve the efficiency of the service, and this requires additional building space to accommodate the equipment. There are no risks to quality from slippage of either of these schemes. These projects will be funded from the Trust’s capital and will incur costs of £0.8m over two years. Maternity unit – the Trust was successful in securing a grant of £325k from the DoH which it has supplemented with approximately £100k of Trust capital to fund a scheme to improve the facilities on the labour suite. This scheme will see improvements to all the patient areas on labour suite, enhancing washing and toilet facilities, upgrading the décor throughout, replacing a birthing pool and making the environment more appropriate for the service provided. The scheme is well underway and will be complete in quarter one of this year and, as such, the risk of slippage is negligible. Ward developments – the Trust has submitted a second stage bid to the DoH improving environment for patients with dementia for £800k. If successful, the funding (with a Trust supplement of £200k) will allow for the refurbishment of two Phase 1 wards to make the environment more appropriate for elderly patients generally and patients with dementia specifically. This project is a key element of the Trust’s strategy of refurbishing patient areas in Phase 1and similar approaches will be adopted in future years. Information Technology – the focus in year one is the upgrade to the Trust’s PACS/RIS system which was successfully implemented during the weekend of 26/27th May. In the remainder of the programme the Trust will be driving forward its plans for an electronic patient record (EPR) and moving towards an increasingly paperless way of working.

Two large engineering schemes are at various stages of completion:


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• Electricity at Work Regulation Compliance is a 3 year programme across the whole SDH site which will be completed in 2013/14.

• Air Handling Unit replacement programme in 2013/14 enters a second (of seven) year investment to replace all units

Cash The continued successful management of the annual revenue position allows the Trust to deliver a significant capital programme for the benefit of patients whilst at the same time achieving a strong cash position. Within the plan, cash is forecast to be £14.33m in 2013/14, £15.764 in 2014/15 and £17.547m in 2105/16. Cash balances in 2012/13 were £17.113 with the reduction between this year and last year being driven by the effect of the £4.4m slippage in the capital programme, with the outflow moving to the current year. The Trust continues to retain a committed Working Capital Facility of £10m and has reflected this throughout the life of the plan. Contingencies and Downside Risk The Trust has managed the downside possibilities by taking a prudent approach to the preparation of the plan. General growth has not been included within the plan although an increase of 1.25% for each of years 2014/15 and 2015/16 has been included although the population during that period could rise by up to 18%, consequently we consider that there is more significant upside possibility rather than downside in the short to medium term. In addition whilst our modelling of tariff indicates a tariff deflation in 2013/14 of less than the nationally indicated 1.1% we have reduced income by £496k in order to cover any risk posed by our approach. The Trust agreed £400k against total PCT challenges of £1.25m in 2012/13 and has provided £700k in 2013/14 given the significance of the commissioning changes. In addition a further £500k has been included in each of 2014/15 and 2015/16 and so we believe that the risks here are well covered. Within the plan we have allowed for full delivery of £1.5m QIPP in 2013/14 and a further £1m in 2014/15 and £2.8m in 2015/16 on the basis that CCG budgets will become ever more pressurised and the move to services delivered out of hospital gathers further pace. With regard to cost we have assumed that pay inflation will double in 2014/15 and remain at 2% for 2015/16. In addition we have included a non-specific cost pressure of 3500k in each of 2014/15 and 2015/16. Consequently we consider that sufficient contingency has been included within the plan to ensure any reasonable downside risk is adequately covered. However should more significant downside risk become apparent the Trust considers that it has sufficient resource and skill to manage such change. Also the Trust Board has previously demonstrated its ability and commitment to act quickly when unexpected risks have presented themselves. The maturing Programme Management Office also provides a further resource to enable rapid change to be driven through the organisation.


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Appendix 2: Cost Improvement Plans (CIPs) - Top 5 CIP Schemes (NOT FOR PUBLICATION)

Note: this schedule is to provide additional information regarding CIPs. Please refer to CIPs guidance on page 5.

Ref

Scheme Scheme description including how

scheme will reduce costs

Under-pinning IT / information

or management

systems

Total

savings £m

Phasing over three-year period

(£000’s)

WTE Reduction Has the scheme been subject to a

quality impact

assessment

(Y/N)

Who is responsible for signing off on

the quality impact assessment

Key measure of quality for plan

Scheme Lead

Yr. 1 Yr. 2 Yr. 3

1 Non Pay / Procure-ment

Ongoing programme that includes: Reduction in cost of maintenance contracts through switching suppliers and using managed services. Plus reduction in cost of consumables.

2.05 850 600 600 nil In progress Medical Director / Nursing Director

Maintain Patient Experience – RTF, Friends & Family test Staff experience – staff survey

Head of Procurement

2 Outpatient Pathway

Standardisation and centralisation (where applicable of the administration processes of Outpatient services, i.e. (templates, booking systems, and capacity & demand)

use of technology – such as ‘self check in’ kiosks. telemedicine

1.2 150 500 550 30 - 50 In progress Medical Director / Nursing Director

Patient Experience – RTF, Friends & Family test Staff experience – staff survey Benchmark against best performers Reduction in complaints associated with cancellations, waiting times etc

Chief Operating Officer / PMO


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Ref




or management

systems

Total

savings £m


(£000’s)


quality impact

assessment

(Y/N)




Scheme Lead

Yr. 1 Yr. 2 Yr. 3

3. Agency Usage Reduction

To identify a safe alternative solution to the use of agency staff to fill short, medium and long term gaps in staffing across all disciplines and specialties

Rosterpro. Recruitment process.

1.0 500 500 0 33 (Agency staff)

In progress Medical Director / Nursing Director

Patient Experience – RTF, Friends & Family test Staff experience – staff survey Benchmark against best performers Matron’s Dashboard

Chief Operating Officer / PMO

4 Bed Capacity Modeling / LoS

Programme concerned with challenge of diagnostic waits, medical rotas / timetables and clinical pathways

Development of in- house bed modeling programme Installation of second CT scanner

0.5 100 200 200 In progress Medical Director / Nursing Director

Patient Experience – RTF, Friends & Family test Staff experience – staff survey LoS reduction Benchmark against best performers Reduction in unplanned escalation

Chief Operating Officer

5 Theatre Utilisation

TMS project, improved utilisation and reduction in additional activity payments to maximise throughput

Theatre Management System. Improved theatre access for emergencies through minimum pre-

0.6 100 200 300 nil In progress Medical Director / Nursing Director

Staff experience – staff survey Benchmark against best performers

Directorate Manager Surgery


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Ref




or management

systems

Total

savings £m


(£000’s)


quality impact

assessment

(Y/N)




Scheme Lead

Yr. 1 Yr. 2 Yr. 3

op LoS. Reduction in cancellations & theatre waiting times. Use of evidence based improvements in surgical care through best practice.


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Appendix 3: PFIs costs and utilisation (NOT FOR PUBLICATION)

At the time of entering the PFI agreement the value for money of this initiative compared favourably with the Public Sector comparator. The PFI was required to replace operational buildings constructed during the Second World War, which were no longer fit for health care purposes. The new accommodation also significantly assists the Trust in enhancing infection control. The original assumptions on which the Trust entered the PFI agreement remain valid today. The PFI Unitary payment comprises 1.76% of the Trust’s total income, which is likely to remain fairly constant over the coming years. The PFI resources are being used for the purposes for which they were originally intended.


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Appendix 4: Use of external assurance (including internal audit) (NOT FOR PUBLICATION)

The Chief Executive Officer has responsibility for maintaining a sound system of internal control that supports the achievement of SFT’s policies, aims and objectives through a system designed to manage risk to a reasonable level. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of Trust objectives, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically.

EXTERNAL ASSURANCE

The Care Quality Commission (CQC) found the Trust to be compliant with all standards relating to hygiene and patient safety. Two minor concerns were raised around record keeping and staffing levels. Action plans have been developed and submitted to the CQC who have confirmed that they will revisit the Trust in the autumn three month after action plans have been completed. This visit will determine whether these concerns have been addressed and whether the concerns will be lifted.

In 2012, the Health and Safety Executive (HSE) served three improvement notices on the Trust. These were all subsequently lifted within 6 months of them being served. The Trust has continued to monitor delivery against action plans that were approved by the HSE to ensure that the improvements are sustained.

During 2012, the Trust engaged the services of an experienced external consultant to support work on preparing the long term strategy document. This provided an additional level of challenge and analysis.

External reports were commissioned to support work to improve outpatient services. These reports explored outpatient activity, management arrangements, staff productivity and the environment. This information has been used to develop a number of CIP’s in this area.

An external review of the Trust’s onsite laundry service was commissioned to develop an action plan aimed at increasing productivity and profitability of the service.

There is an agreed programme of internal and external audits each year. These are agreed by the Finance Committee (a Board sub-committee) which also has responsibility for reviewing the findings of the audits and ensuring that those findings are implemented. The Trust’s internal audit and counter-fraud service is provided by South Coast Audit. Those reviews that have reported to the Audit Committee in the 2012/13 programme so far are:

• Contract income • NHS Contract (SLA monitoring) • Induction Process (including Mandatory training) • Energy Management • Critical Financial Assurance Payroll/ESR • Mortality and Morbidity • Bank & Agency Administration


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The internal audit programme for 2012/13 includes a review of the Assurance Framework, compliance with the CQC’s outcomes, service line reporting, doctors’ appraisals and companies owned by the Trust. A report is categorised as Limited Assurance if it contains any high priority recommendations and in the case the two reports listed above, improvement actions have been identified and are being implemented.

The Trust has engaged the services of external consultants (Newtons) to provide assurance that the planned programme of Cost Improvements is realistic and deliverable, and to identify further areas where savings could be made.


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Appendix 5: Commercial or other confidential matters (NOT FOR PUBLICATION)

All commercial matters are fully covered within the main document.

Documents

Strategic Plan Document for 2013-14 NHS Foundation Trust · Strategic Plan 2013 – 16 1 1. Executive Summary This Strategic Plan 2013-16 sets out how Salisbury NHS Foundation Trust