SUMMARY REPORT 1.14.035 (App 7)

TRUST BOARD 24th April 2014

Subject Trust Business Plan 2014/15 to 2015/16

Prepared by Nigel Timmins, Strategic Planning Manager

Approved by Lezli Boswell, Chief Executive

Presented by Ethna McCarthy, Director of Strategy and Business Development

Purpose

The objective of this report is to present the Trust’s Business Plan covering the period 2014/15 to 2015/16.

Receive

Approve

Trust Objectives

Quality People Partnership Resources

Executive Summary

This Business Plan fulfils the TDA requirement for the Trust to have in place a two year operational plan. Additionally the Trust is required to prepare a five year strategic plan which must be approved by Board in May 2014.

In developing this plan we have taken into account national planning guidance and local commissioning intentions. It reflects planned corporate developments and also plans at divisional and specialty levels in response to their specific environments.

The strategic context for the business planning is set by the Trust’s vision and strategic aims, underpinned by its values. These have been updated during February and March 2014 and this plan is based on the updated version.

The plan embraces the drive to better align our resources to deliver high quality, flexible capacity and to meet the quality expectations of the post-Francis world. It is also framed in the context of the drive towards integrated care.

Our Vision is :

‘Working together to achieve outstanding care and better health outcomes’

Our ambition is underpinned by our four Strategic Aims:

Quality - we will provide outstanding health care services that are safe, responsive, accessible and effective to meet patients’ needs and achieve best in class performance.

People - we will make best use of our expert skills and capabilities, invest in education, training and research to continually improve our practice, and offer fulfilling and valued careers.

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Partnership -we will collaborate and innovate with our partners to deliver integrated, patient-focussed pathways of care, and be the provider of choice in Cornwall.

Resources - we will be financially sustainable and make efficient use of our resources to provide safe and welcoming environments, modern equipment, and technology, to underpin service transformation.

The plan sets out the outcomes, objectives and performance indicators through which we will hold ourselves to account. It confirms the proposed budget, workforce and activity plan – however these may be subject to some adjustment following completion of the contracts with Commissioners.

The year will be challenging, we need to :

recover ground with regard to C Diff; CIPs, productivity and operational performance;

build on the learning from Governance reviews in 2013 and on the outcome of the CQC inspection;

work closely with partners to develop and test the emerging model of Integrated Care in Cornwall and Isles of Scilly, to stem growth in urgent care and contain elective growth to planned levels.

Key Recommendations

The Board is asked to approve the plan subject to contract completion.

Assurance Framework

The Board Assurance framework will be refreshed for 2014/15, once the strategic Aims and expected outcomes have been approved by Trust Board.

Next Steps

The next steps will be the completion of the 5 year plan, including refresh of key strategies, and finalisation of the plan for 2014/15 in light of the contract agreements.

Corporate Impact Assessment

CQC Regulations Supports CQC compliance

Financial Implications Detailed financial plan for 2014/15 is appended to this plan

Legal Implications None

Equality & Diversity None

Performance Management Variations to plan will be addressed through the Performance assurance review process.

Communication Vision, Aims, Outcomes to be communicated widely across the Trust.

Acronyms / Terms used in Report

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AHSN AQP BAF BCF CIP CQC CRS CSDP DH F&FT FT IMT ISTC PLACE R&D RMS RTT SDMP SLM TDA WSDG

Academic Health Science Network Any Qualified Provider Board Assurance Framework Better Care Fund Cost Improvement Plan Care Quality Commission Carbon Reduction Strategy Clinical Site Development Plan Department of Health Friends and Family Test Foundation Trust Information Management Technology Independent Sector Treatment Centre Patient Led Assessment Care Environment Research and Development Referral Management Service Referral to Treatment Sustainable Development Management Plan Service Line Management Trust Development Authority Whole System Delivery Group

 

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TABLE  OF  CONTENTS  

1  EXECUTIVE SUMMARY ............................................................................................................................... 5 

1.1  CONTEXT   5 

1.2  VISION AND STRATEGIC AIMS  5 

1.3  STRATEGIC DRIVERS   6 

1.4  CORE PLANNING EXPECTATIONS   6 

1.5  STRATEGIC ENABLERS   7 

1.6  QUALITY IMPROVEMENT, PERFORMANCE AND RISK MANAGEMENT   7 

2  INTRODUCTION ............................................................................................................................................ 8 

2.1  RESPONDING TO A CHANGING ENVIRONMENT   8 

2.2 OUR COMMUNITY   9 

2.3 REFLECTIONS ON 2013/14   10 

2.4 CARE QUALITY COMMISSION INSPECTION  11 

2.5 KEY STRATEGIC DRIVERS  11 

3  OUR PLANS 2014/15 – 2015/16 .............................................................................................................. 13 

3.1 OUR VISION   13 

3.2 OUR VALUES  13 

3.3  STRATEGIC AIMS  14 

3.4  STRATEGIC AIM ONE - QUALITY   14 

3.5  STRATEGIC AIM TWO - PEOPLE  15 

3.6  STRATEGIC AIM THREE - PARTNERSHIP   15 

3.7  STRATEGIC AIM FOUR - RESOURCES  15 

4 STRATEGIC AIM ONE – QUALITY ................................................................................................. 16 

4.2  PATIENT SAFETY  16 

4.3  CLINCAL EFFECTIVENESS  17 

4.4  PATIENT EXPERIENCE   18 

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4.5  CQUIN (COMMISSIONING FOR QUALITY AND INNOVATION)  18 

4.6  QUALITY ACCOUNTS   19 

4.7  SERVICE LINE MANAGEMENT   20 

4.8 MEASURING STRATEGIC AIM ONE - QUALITY   21 

5 STRATEGIC AIM TWO – PEOPLE ................................................................................................. 23 

5.2  NATIONAL STAFF SURVEY   24 

5.3  OUR PEOPLE STRATEGY  25 

5.4  WORKFORCE PLANNING   26 

5.5 RESEARCH, DEVELOPMENT AND INNOVATION  26 

5.6 ACADEMIC HEALTH SCIENCE NETWORK   27 

5.7 MEASURING STRATEGIC AIM TWO - PEOPLE   28 

6 STRATEGIC AIM THREE – PARTNERSHIP ................................................................................ 29 

6.1  CONTEXT   29 

6.2  PATHWAY CHANGES AND MARKET OPPORTUNITIES   29 

6.3  WHOLE SYSTEMS GOVERNANCE   30 

6.4  BETTER CARE FUND   31 

6.5  INTERGTRATED CARE PIONEER: LIVING WELL  31 

6.6  GP ENGAGEMENT   32 

6.7  RESPONDING TO THE MARKET  32 

6.8 MEASURING STRATEGIC AIM THREE - PARTNERSHIP  33 

7 STRATEGIC AIM FOUR - RESOURCES ....................................................................................... 35 

7.1  FINANCIAL PLANNING   35 

7.2  INCOME  36 

7.3  EXPENDITURE AND SAVINGS   37 

7.4  PROJECTED ACTIVITY, DEMAND AND CAPACITY   37 

7.5  CAPITAL EXPENDITURE  38 

7.6  COST IMPROVEMENT PROGRAMME   39 

7.7  SUSTAINABLE DEVELOPMENT   41 

7.8  MEASURING STRATEGIC AIM FOUR - RESOURCES  42 

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8  SERVICE PLANNING AND DEVELOPMENT ........................................................................................ 43 

8.2  KEY PRIORITIES FROM DIVISIONAL AND SPECIALTY PLANS  44 

9 GOVERNANCE, RISK MANAGEMENT AND ASSURANCE ...................................................... 45 

10 PERFORMANCE MANAGEMENT ................................................................................................... 45 

APPENDIX 1 FINANCIAL PLAN 2014/15 (SUPPORTING STATEMENTS).................................... 48 

1.  STATEMENT OF COMPREHENSIVE INCOME ............................................................................................. 48 

2.  EXPENDITURE ................................................................................................................................................ 49 

3  BALANCE SHEET AND CASH FLOW ............................................................................................................ 49 

4  CAPITAL PROGRAMME ................................................................................................................................. 50 

APPENDIX 1.1 TO THE FINANCIAL PLAN 2014/15 – STATEMENT OF COMPREHENSIVE INCOME ......................................................................................................................................................... 51 

APPENDIX 1.2 TO THE FINANCIAL PLAN 2014/15 – BALANCE SHEET .......................................... 52 

APPENDIX 1.3 TO THE FINANCIAL PLAN 2014/15 – STATEMENT OF CASH FLOWS ................ 53 

APPENDIX 1.4 TO THE FINANCIAL PLAN 2014/15 – CAPITAL PROGRAMME AND FINANCING (2014/15 AND 2015/16 ARE APPROVED, SUBSEQUENT YEARS ARE INDICATIVE) ............. 54 

 

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1 EXECUTIVE SUMMARY

1.1 CONTEXT

1.1.1 This business plan fulfils the TDA requirement for the Trust to have in place a two year operational plan. Additionally the Trust is required to prepare a five year strategic plan which must be approved by the Trust Board in May 2014.

1.1.2 In developing this plan we have taken into account national planning guidance and local commissioning intentions. It reflects planned corporate developments and also plans at Divisional and Specialty levels, in response to their specific environments.

1.1.3 The context for the business plan is shaped by the Trust’s Vision and Strategic Aims, underpinned by its Values. These have been updated during February and March 2014 and this plan is based on the updated version.

1.1.4 The plan embraces the drive to better align our resources to deliver high quality, flexible capacity and to meet the quality expectations of the post-Francis world. It is also framed in the context of the drive towards integrated care and is consistent with the developments planned in response to the CQC inspection.

1.2 VISION AND STRATEGIC AIMS

1.2.1 Our Vision is:

Working together to achieve outstanding care and better health outcomes

This is underpinned by four Strategic Aims:

1.2.2 The plan sets out the outcomes we expect to achieve, and the detailed metrics which will be used to measure progress.

Quality ‐ we will provide outstanding health care services that are safe, responsive, accessible and effective to meet patients’ needs and achieve best in class performance

Partnership ‐ we will collaborate and innovate with our partners to deliver integrated, patient‐focused pathways of care, and be the provider of choice in Cornwall

People ‐ we will make best use of our expert skills and capabilities, invest in education, training and research to continually improve our practice, and offer fulfilling and valued careers 

Resources ‐ we will be financially sustainable and make efficient use of our resources to provide safe and welcoming environments, modern equipment, and technology, to underpin service transformation 

Working together to achieve outstanding care 

and better health outcomes

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1.3 STRATEGIC DRIVERS

1.3.1 Nationally the NHS is undergoing one of the most challenging periods in its history with the pressing need to improve quality following the Francis1 and Berwick2 reports; the significant financial challenge; structural changes in how the NHS is run and regulated; and rising patient expectations.

1.3.2 Locally the vision of integrated care is being developed and evaluated by NHS Kernow, and sets the context for partnership working to ensure improvements in the quality of care. The aim is to provide as much of each pathway as close to patients’ homes as possible, as well as living within the tight public finance constraints.

1.3.3 The vision also describes plans for enhanced Community Services around GP Federations/Localities, redesign of Urgent Care, changes to ‘Community Elective Services’ and other changes which will impact on the scope and shape of acute services. Our challenge is to work in partnership to achieve these aims, but in an environment of high levels of demand and the need to assure patient safety above all else.

1.4 CORE PLANNING EXPECTATIONS

1.4.1 Our key deliverables for 2014/15 will be finalised once the contracts with NHS Kernow and NHS England are completed; but are expected to be in the range below:

FINANCE £000 ACTIVITY TYPE NUMBER WORKFORCE WTE

INCOME 329.3 ELECTIVE 65,456 1 APRIL 2014 5018

EXPENDITURE 325.4 NON ELECTIVE 37,588 DEVELOPMENTS 60

SURPLUS 3.9 OUTPATIENTS 497,203 CIP/TUPE (*) (580)

CIP 14.0 ED 66,171 31 MARCH 2014/15 4498

CAPITAL EXPENDITURE

21.7

(*) Dependent on outcome of the Hotel Services procurement

1.4.2 The achievement of improved productivity is essential to underpin the delivery of these volumes within our resources and within target access times. The delivery of CIP will be challenging, and require close alignment with activity planning and pathway redesign.

                                                            

1 Francis Report ‘One Year On’ published on 6 February 2014

2 Berwick Report published in August 2013

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1.5 STRATEGIC ENABLERS

1.5.1 To achieve the desired outcomes, the following key Trust wide enabling projects must be resourced and delivered:

Implementation and adherence to key pathways of care,

Service Line Management, as a framework for quality improvement and financial stability

IMT infrastructure upgrade, to be fit for the next 5-10 years

Replacement of PAS and development of new EPR

Capital investment in estates and facilities

Creation of new, flexible employment framework

Development of intelligence at Specialty and Consultant level to drive quality

Joint scenario modelling work with partners to underpin major service changes in future

1.6 QUALITY IMPROVEMENT, PERFORMANCE AND RISK MANAGEMENT

1.6.1 Quality improvement (safe, effective and timely care) will drive our performance culture in 2014/15. The targets and actions set out with the plan will be included in the Integrated Performance Report for 2014/15, and, once approved, the critical risks and mitigations will be included with the Board Assurance Risk Framework.

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2 INTRODUCTION

2.1 RESPONDING TO A CHANGING ENVIRONMENT

2.1.1 Nationally the NHS is undergoing one of the most challenging periods in its history:

The pressing need to improve quality following the Francis3 and Berwick4 reports

The significant financial challenge

Structural changes in how the NHS is run and regulated

Rising patient expectations

2.1.2 This environment makes it ever more essential that individual NHS Trusts have effective arrangements in place to perform in short term but also to develop transformational plans that meet the challenge sustainably over the longer term. This requires Trusts to be able to identify and to respond to the challenges ahead. For example by:

Developing a better understanding of how quality can drive redesign and reduce costs

Helping to realise the ambitions of the Better Care Fund and integrated care

Achieving the shift to 24/7 working across more services, to achieve better outcomes

2.1.3 The NHS planning environment is supported through national guidance. In the document ‘Everyone Counts: Planning for Patients 2014/15 to 2018/1959, NHS England sets out the principles behind the new approach to clinically-led commissioning. This confirms that the NHS Outcomes Framework6 and NHS Constitution5 remain constant in providing goals and describing responsibilities but recognises that the approaches for delivery will vary and local commissioners will have freedom to develop those that work in their community.

2.1.4 This plan combines the strategic direction set by the Board with the aggregation of the outcomes from the Trust’s divisional and speciality planning process. It reflects our ambition to have a clinically-led business planning process. Each of the clinical Divisions and main support services have developed their own business plan providing detail behind their key challenges, quality goals and how their stated objectives in contribute to the overall Trust strategy.

2.1.5 Previously the Trust outlined its ‘2018 Strategy’ within ‘Our Plans 2012-2017’.7 The clinical direction is toward excellent, integrated care, delivered throughout Cornwall, to

                                                            3 Francis Report ‘One Year On’ published on 6 February 2014

4 Berwick Report published in August 2013

5 Everyone Counts: Planning for Patients 2014/15 to 2018/19 published in December 2013

6 NHS Outcomes Framework published 15 November 2013

7 2018 Strategy’ ’within ‘Our Plans 2012-2017’ published in 2012

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meet the needs of the population. This business plan builds upon these plans and aspirations. It covers the two years 2104/15 and 2015/16, and will underpin a new 5 year plan to be submitted to the TDA in June 2014. This will also be aligned with the 5 year Commissioner plans.

2.1.6 Over the next two months therefore, we will review our key strategies, confirm our operational plans in light of the 2014/15 contract, and agree priorities with our partners, linked to the development of the Better Care Fund and achievement of integrated working.

2.2 OUR COMMUNITY

2.2.1 Cornwall and the Isles of Scilly have a rich and vibrant history, with a strong culture and sense of identity. It is a beautiful part of the British Isles in which to live, with an important tourist and holiday business. And, like any part of the country, it has its own distinct health and social care needs.

2.2.2 There are 534,000 people living in Cornwall and the Isles of Scilly (based on the Census 2011 data). The majority look to RCHT for their care. Among this population:

Cornwall and the Isles of Scilly have a more elderly population than the rest of the country

the local population is growing quickly, by around 5% from 2010 to 2016, with the greatest growth in groups over 65 years of age and the youngest age groups, reflecting high birth rates (where the number of births increased by 17% from 2001 to 2008)

there are significant pockets of deprivation in the county, which bring their own healthcare needs and requirements, including issues concerning access to care

Cornwall is a rural county with a widely dispersed population. In addition, the Isles of Scilly provide a further challenge in access to care.

2.2.3 In addition, at the height of the tourist season, there can be around 300,000 extra people in the county and this can mean our emergency department faces high levels of attendances in the summer months, especially in July and August, in addition to the usual winter demands experienced by all hospitals across the UK.

2.2.4 This creates particular healthcare demands and delivery challenges. The Trust is planning future care, in response to these challenges. We provide services across a range of sites in the county harnessing our local community hospitals, and we provide flexible capacity to meet the local profile of need.

2.2.5 The Trust is the principal provider of acute, specialist and community healthcare to the people of Cornwall and the Isles of Scilly. We are a medium sized teaching District General Hospital, primarily providing services on three hospital sites: Royal Cornwall Hospital in Truro, West Cornwall Hospital in Penzance and St Michael’s Hospital in Hayle. Increasingly we are expanding our offer to include more locations and delivery through technology and telephone contact, in order to meet patient and GP needs.

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2.2.6 Our care services include:

Emergency and urgent care health services

Maternity and paediatric services

A range of community and specialist services to provide for the health needs of people needing planned care.

2.3 REFLECTIONS ON 2013/14

2.3.1 The Trust has experienced a challenging year and this reflects in the mix of performance against our key priorities. However, we have, through the creative efforts and dedication of all of our team, retained ‘DH Preforming status’, achieving many positive outcomes. Targets have been achieved in key performance areas such as cancer and fractured neck of femur. We have accommodated increased levels of demand for both elective non elective services and seen the beginnings of improvements in staff engagement as evidenced through improvements in the staff survey.

2.3.2 In other areas however, performance has fallen below expected levels e.g. with regard to ED targets, backlog lists under RTT, infection rates, increase in the number of Never Events reported and part achievement of our CIP target. In addition the Board are acutely aware that the pressures of high demand have disrupted other services and resulted in a poor patient experience on some occasions.

2.3.3 The Board have demonstrated absolute commitment to the learning from key national reviews such as the Frances Report and the Berwick Report, and been transparent in reporting and addressing some underlying governance weaknesses had not been fully exposed and resolved in the past. Thus much time, resource and effort has been given to addressing the root causes and working with teams to set the foundations for sustainable improvement, and ensuring that all staff feel empowered to raise concerns.

2.3.4 Changes in the membership of the Trust Board created a short period of instability, but swift actions and close working with the TDA has now resulted in new, highly talented members joining the Trust Board, further strengthening our strategic capability.

2.3.5 The Trust has remained as an FT applicant with Monitor however the assessment has paused pending the outcome of the CQC report. It is now expected that the improvement actions will take around 6 months to be fully embedded, after which the CQC will need to confirm ‘Good’ overall before the FT assessment will recommence. Successful completion of the application will also be critically dependent on maintaining quality and performance across all indicators and refreshing the critical elements of our Business Plan and Long Term Financial Model both of which must be in the context of a sustainable health economy position.

2.3.6 2014/15 will continue to be challenging, as resource constraints impact. Thus it is even more imperative that all partners within the Health and Social Care system work together to design effective and affordable services, engaging the public in this process. As an aspirant FT, we will continue to involve members and governors, in shaping the future of

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acute services, particularly in the context of Locality planning and the need to have close alignment with GPs.

2.4 CARE QUALITY COMMISSION INSPECTION

2.4.1 The Care Quality Commission (CQC) carried out a full inspection of the RCHT in January 2014, the Trust being one of the first Trusts to be inspected under the new CQC inspection regime. The inspection focused on whether services are safe, effective, caring, responsive to peoples’ needs and well-led and covered eight service areas across the three RCHT sites.

2.4.2 The Trust received the final copy of the inspection report on 21st March 2014. CQC found that many of the services provided by the Trust were delivered to a good standard. The Trust received ‘Good’ ratings for West Cornwall Hospital and St Michael’s Hospital and ‘Requires Improvement’ for Royal Cornwall Hospital. The rating of ‘Requires Improvement’ recognises the Trust is on an improvement path towards a ‘Good’ rating.

2.4.3 The Trust has developed an improvement plan detailing the actions that will be taken to address the recommendations in the report. The two main actions relate to:

- Better management of patients’ records including their safe keeping, accuracy and completeness

- Improved planning and delivery of services, involving working with partners in the health and social care community, to ensure that pressures and shortfalls in capacity are better managed.

2.4.4 Looking forward, we plan to be in a position to request a re-inspection of our services in 6-9 months with the aim of being rated as ‘Good’. The next ambition will be to achieve the highest rating under the CQC inspection regime of ‘Outstanding’. However, the achievement of this is dependent on whole system change in health and social care in our area.

2.5 KEY STRATEGIC DRIVERS

2.5.1 Taking the context and learning described above, into account, our key strategic drivers for the next two years can be summarised as follows:

a) The opportunity of new leadership, vision and values, to embed a culture of openness and trust, deliver safe services and achieve better staff engagement.

b) The emergence and development of the Strategic Vision for Cornwall and Isles of Scilly, and implications for RCHT as acute provider.

c) Clinical drivers such as ‘Hospital of the Future’8 , which set out the challenges to meet best modern practice for medical patients, to be fit for the future.

d) The opportunity to be more creative in actively involving patients in service design and , focus on patient needs rather than organisational process and structure,

e) The continued importance of robust quality governance, embedded at Specialty level taking forward our learning from our CQC assessment and other events in 2013/14.

                                                            8 Hospital of the Future’ published September 2013

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f) A critical need to improve performance, productivity and strengthen accountability , in the context of a quality focus.

g) Alignment of workforce, activity and resources – giving high quality, flexible capacity.

h) The need to be agile and creative, to exploit the potential of provider, networks and other market opportunities.

i) Formulation and delivery of the key transformational, IMT projects to move to electronic records and paperless working, improving care and outcomes for patients.

j) Continue the FT application, encapsulating all of the above.

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3 OUR PLANS 2014/15 – 2015/16

3.1 OUR VISION

3.1.1 To achieve our vision we will always put patients first, and strive to provide consistent high quality care. Achieving this ambition will challenge us to redesign pathways of care around patients, make services more accessible for patients and GPs and to have in place staff, systems and facilities that of are the highest quality. This will have to be executed in tandem with a continuous need to reduce costs, and we recognise the need to work with partners in order to deliver this ambition.

3.2 OUR VALUES

3.2.1 Everything we do is based around a set of core values. These are the attitudes and behaviours we identify as fundamental to delivering our vision. Following an extensive process of staff engagement, these are:

3.2.2 During 2014/15 the Values will become integrated into all of our practices, so that all staff will be fully aware of, and demonstrate behaviours consistent with the Values thus shaping our culture.

Working together to achieve outstanding care and better health outcomes 

            Care + compassion 

Inspiration + innovation 

Working together 

             Pride + achievement 

  Trust + respect 

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3.3 STRATEGIC AIMS

3.3.1 To support our vision and our values, the Trust has developed four strategic aims:

3.3.2 We will assess our success in the achievement of our Aims through the visibility of the following outcomes by 2016:

3.4 STRATEGIC AIM ONE - QUALITY

We will provide outstanding health care services that are safe, responsive, accessible and effective to meet patients’ needs and achieve best in class performance.

Outcomes by 2016:

Consistent and safe services across 7 days -‘’24/7’’

Standardised, person centred pathways of care

Consistent NHS upper quartile performance and more ambitious benchmarks as appropriate

Excellent feedback from patients, carers, families, staff and our partners

Quality ‐ we will provide outstanding health care services that are safe, responsive, accessible and effective to meet patients’ needs and achieve best in class performance

Partnership ‐ we will collaborate and innovate with our partners to deliver integrated, patient‐focused pathways of care, and be the provider of choice in Cornwall

People ‐ we will make best use of our expert skills and capabilities, invest in education, training and research to continually improve our practice, and offer fulfilling and valued careers 

Resources ‐ we will be financially sustainable and make efficient use of our resources to provide safe and welcoming environments, modern equipment, and technology, to underpin service transformation 

Working together to achieve outstanding care 

and better health outcomes

The desired outcome to be met through our Aims is:

– to be recommended by Friends and Family as an excellent to place to be treated and a great place to work. To be recognised as making a difference 

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3.5 STRATEGIC AIM TWO - PEOPLE

We will make best use of our expert skills and capabilities, invest in education, training and research to continually improve our practice, and offer fulfilling and valued careers.

Outcomes by 2016:

Inspirational multi-disciplinary leadership and effective management of all of our services

A resilient workforce that is proud to work for Royal Cornwall Hospitals Trust and effective and efficient deployment of our expert skills and capabilities

A thriving research, improvement and innovation portfolio that informs and improves patient outcomes

3.6 STRATEGIC AIM THREE - PARTNERSHIP

We will collaborate and innovate with our partners to deliver integrated, patient-focused pathways of care and be the provider of choice in Cornwall and Isles of Scilly

Outcomes by 2016:

New service models aligned with NHS Kernow’s integrated vision for health and social care

Create a new service offer in East Cornwall in response to the ISTC contract, and achievement of growth under AQP

Strengthened clinical networks, new joint care models and partnership ventures to underpin the viability of services in Cornwall and Isles of Scilly

3.7 STRATEGIC AIM FOUR - RESOURCES

We will be financially sustainable and make efficient use of our resources to provide safe and welcoming environments, modern equipment, facilities, and technology, to underpin service transformation...

Outcomes by 2016:

Achieve planned surpluses of £3.9m each year

Best in class productivity and efficiency standards , delivered through quality assured CIPs

Completion of our sites development plan phase 1, and achievement of expected patient and business benefits

Fully utilised and robust, electronic patient care and management systems, supporting high quality, efficient care

Successful work with partners to achieve our sustainability goals adding value to the economic health of Cornwall and Isles of Scilly

3.7.1 Each of our strategic aims, the key related issues, specific objectives and performance measures are described in further detail below.

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4 STRATEGIC AIM ONE – QUALITY

We will provide outstanding health care services that are safe, responsive, accessible and effective to meet patients’ needs and achieve best in class performance.

4.1.1 Our ambitions on quality are driven by our commitment to focus relentlessly on improving quality and safety. Quality improvement is the underpinning principle in our planning and deliver.

4.1.2 For 2014/15 to 2015/16, the focus will be on:

a) Patient Safety - the quality and safety of patients being the top priority – using the Safety Thermometer as a measure of success; ensuring that we continue to improve our care for the frail and elderly

b) Clinical effectiveness - Identifying patients at high risk of admission to secondary care, to reduce re-admissions. Use more granular information to inform discussions on mortality rates at specialty and HRG level

c) Patient experience - Work closely and effectively with partners, deliver on our Experience and Involvement Strategy – continue to work as part of a system of care, with patients at the centre.

4.2 PATIENT SAFETY

4.2.1 Following the Francis and Berwick Reports, the Trust has plans to ensure that it has addressed the recommendations pertinent to re-enforcing our arrangements for Board assurance on patient safety, quality and compliance. The Board has received reports by the Nurse Executive and a programme of work has been developed for delivery in 2014/15 and 2015/16.

4.2.2 A key aspect of maintaining patient safety, quality and compliance is having robust systems of monitoring and escalating forecast variance in performance. The Integrated Governance Strategy provides a framework within which the Trust can provide robust evidence through its governance and assurance framework to demonstrate its compliance with the necessary quality and safety standards relevant to an NHS provider organisation.

Outcomes by 2016:

Consistent and safe services across 7 days -‘’24/7’’

Standardised, person centred pathways of care

Consistent NHS upper quartile performance and more ambitious benchmarks as appropriate

Excellent feedback from patients, carers, families, staff and our partners

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4.2.3 This includes but is not limited to:

CQC Registration Regulations (Health Act 2008) – maintaining unconditional registration

Quality Accounts national framework

NHSLA Risk Management standards

Information Governance Toolkit

Commissioners’ performance monitoring framework

Monitor’s Financial and Governance requirements

4.2.4 Safety Thermometer data is presented as a “harm free” care rating and has become an important benchmark in understanding safety in our inpatient areas. We routinely report information on performance in this area in the monthly Integrated Performance Report to Board. Our performance on harms caused during 2013/14 (up to and including January 2014) is close to the national position:

RCHT harms caused 6.7% versus national position 6.5%

RCHT pressure ulcers 5% versus national position 4.7%

4.2.5 Throughout the 2013/14, the Trust has experienced high levels of urgent care demand. Although there is no single influencing factor behind the increase, many of the patients are frail and elderly, requiring a higher level of care to keep them safe. When caring for a frail elderly person, the risk of falling and serious injury increases, and returning to activities of daily living becomes more difficult. This makes care packages more complex to organise and more difficult to facilitate a timely discharge or transfer to another care provider.

4.3 CLINCAL EFFECTIVENESS

4.3.1 Clinical effectiveness is made up of a range of quality improvement activities and initiatives. These include clinical audit, measurement of patient experience and means of assessing the effectiveness and evidence of treatments and services.

4.3.2 Through the roll-out of service line management and a move to more tailored reporting, focussed on specific service areas and individual clinicians, there will be an increased opportunity to focus on clinical effectiveness and patient experience outcomes. This will also enable improved governance at department, specialty, and ward and consultant level.

4.3.3 As part of determining clinical effectiveness, a governance dashboard is being used monthly to measure performance and is being developed for roll-out as a Specialty Performance Assurance Framework.

4.3.4 Divisions have identified actions to improve their governance structures and processes. Divisional and specialty plans are considered later in this plan.

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4.4 PATIENT EXPERIENCE

4.4.1 We are committed to understanding and improving the patient experience. We do this by improving public and patient involvement and by using feedback to identify trends and themes. Improvements are being made to information and communication. The overriding principle is to demonstrate that feedback influences service design and delivery. Our approach is embedded in the Experience and Involvement Strategy.

4.4.2 The Strategy demonstrates we recognise and appreciate the benefits of public and patient experience and involvement activity and are committed to developing systems and processes to enable this activity to take place.

4.4.3 Patients and the public are increasingly aware of how they can influence service planning and delivery and will be given the support needed, including the right information in an accessible format, to enable this involvement to take place.

4.4.4 The Trust seeks to demonstrate how patient feedback and involvement has made a difference and ensures this information is shared with our stakeholders.

4.4.5 Key deliverables for 2014/15 and 2015/16 are:

• Progressing the Patient Experience Group and the Patient Information Sub-Group

• Revised monthly patient survey and the further embedding the ‘friends and family’ question – making patient feedback count

• Involving the traditionally hard to reach through the ‘It’s a kind of magic’ project; continuing to develop ways to encourage children and people with learning disabilities to give feedback on the services they receive

4.4.6 In March 2013, ahead of the required deadline, the Trust commenced the Department of Health (DH) Friends & Family Test (F & FT) to receive timely feedback from patients about their care and treatment. The overall response rate for the most recent inpatient questionnaire was 21%; this is above the 15% target set by the DH. Our F & FT net-promoter score for in-patients for January 2014 was 68 (based on 533 responses). This is an improvement on the score for December 2013 of 64. The Trust’s scores for the period April to December 2013 were at, or above, the national average.

4.4.7 The net-promoter score is calculated using the proportion of patients who would strongly recommend the ward to friends and family minus those who would not recommend the ward, or who are indifferent.

4.5 CQUIN (COMMISSIONING FOR QUALITY AND INNOVATION)

4.5.1 The CQUIN framework is a national scheme that incentivises providers and commissioners to work together to raise quality and develop innovative approaches to healthcare provision. It does so by making a proportion of providers’ income conditional on the achievement - or progress towards achievement – of jointly agreed goals. These are a mixture of nationally mandated and locally agreed quality improvement and innovation goals.

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4.5.2 We agree targets with NHS Kernow that reward the Trust for achieving agreed quality goals. CQUINS will continue to have a value of 2.5% on top of the core contract value for 2014/15. There are three national areas targeted in 2014/15 being the Friends and Family Test, the Safety Thermometer (focusing on pressure ulcers) and dementia. As usual, this will constitute 20% of the CQUIN programme with the remaining 80% being locally agreed.

4.5.3 The Trust will have CQUIN programmes in 2014/15 with NHS England and NHS Kernow; however the detail has yet to be agreed at the time of writing but will cover key areas such as Dementia, Friends and Family and Patient Flow goals. Ideally CQUINs should be agreed across providers, to provide mutual incentive for change.

4.6 QUALITY ACCOUNTS

4.6.1 Quality Accounts are annual reports to the public from providers of NHS healthcare services about the quality of services they provide. The Trust's stakeholders can use the Quality Accounts to help them understand:

What we are doing well

Where improvements in the quality of our services are required

Our priorities for improvement for the coming year

How these will be achieved including arrangements for measuring, reporting on and monitoring progress

4.6.2 Quality Accounts therefore aim to enhance accountability to the public and engage the leadership of an organisation in the quality improvement agenda. Our most recent audited Quality Accounts were published in June 2013 and were made available as a public document..

4.6.3 Key areas of quality focus were in relation to:

Patient safety - Safety Thermometer: reducing harms

Clinical effectiveness – preventing re-admissions from high risk patients

Clinical effectiveness - staff health and well being

Patient experience - improving the discharge experience for patients and reducing unnecessary discharge delays

Patient experience - CARE campaign

4.6.4 NHS England published the reporting requirements for the 2014/15 quality accounts in January 2014. Trusts are required to share the draft quality accounts with commissioners and local scrutineers for comment by the 30 April. Our planned priorities for improvement in 2014/15 are:

Patient safety – reducing our Hospital Standard Mortality Ratio

Patient safety – implementation of Hospital 24/7

Clinical effectiveness – improvement in National Staff Survey Results

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Clinical effectiveness – implementation of three new patient pathways (chest pain, heart failure and pneumonia)

Patient experience - improving discharge arrangements for patients

4.7 SERVICE LINE MANAGEMENT

4.7.1 Service line management (SLM) is an important mechanism to support quality improvement. It is a well-established framework that enables NHS trusts to understand their performance and organise their services in a way which benefits patients and delivers efficiencies for the organisation.

4.7.2 SLM supports the management of distinct operational units (service lines) and provides a structure within which clinicians can take the lead on service development and performance, resulting in better patient care.

4.7.3 Trusts that have implemented SLM report a number of benefits:

Engaging front-line staff in service performance analysis and decision making

Improving clinical leadership

Improving service line efficiency and productivity

Improved patient care

4.7.4 Many Trusts have adopted an incremental approach to implementing SLM. This initially involves service line pilots and the development of service line financial and performance reports followed by more general roll-out of the programme across the Trust.

4.7.5 This is the approach taken by the Trust. We are working with pilot areas: ENT/Audiology, Sexual Health and Clinical Imaging to develop and test the framework. The Trust plans to take a decision early in 2014/15 about the pace of the wider roll-out of SLM across the Trust. Delivery of SLM will require significant investment by the Trust.

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4.8 MEASURING STRATEGIC AIM ONE - QUALITY

Category Performance Indicator 2013/14 Actual 2014/15 Target 2015/16 Target

Quality – We will provide outstanding health care services that are safe, responsive, accessible and effective to meet patients’ needs and achieve best in class performance.

Outcome 1.1 - Consistent and safe services across 7 days (24/7)

Safety

Hospital Standardised Mortality Ratio (HSMR)

104.5 100 98

New Never Events declared 2 0 0

Serious Incidents 75 65 55

Healthcare Associated Infections

MRSA bacteraemia 3 0 0

Clostridium Difficile post 72 hours 42 35 29

Overall external ratings

Intelligent Monitoring Report score (new CQC regime : 1 = highest risk/6 = low)

n/a (new process) Below 5 Elevated risks/ Banding > 3

4 Elevated risks/Banding > 4

Monitor compliance – service performance rating

2 (concerns) Compliant (no

concerns) Compliant (no

concerns)

CQC Hospital Inspection Improving Good Good

Outcome 1.2 - Standardised, person centred pathways of care

Stroke Acute phase only - % of patients who have spent more than 90% of their time in a stroke unit

64% 70% 75%

NoF

Fractured Neck of Femur - Percentage of patients receiving surgery in 36 hours

74% 75% 75%

VTE Venous Thrombo-Embolism (percentage of eligible patients with a risk assessment)

96% 96% 96%

Implement Frailty Pathways and offer expert, advice to support partners, as part of ‘’Pioneer’’

Embed effective acute frailty service in hospital

Achieve assessment standards

Redesign community frailty / geriatric services to offer better support to primary and community care partners

n/a

Range of experience and

outcome KPIs, to be agreed with Frailty Steering

Group

Range of experience and outcome KPIs, to be agreed with Frailty

Steering Group

Outcome 1.3 - Consistent NHS upper quartile performance targets and higher benchmarks as appropriate

Access and waiting times

Emergency Department performance – above 95%

91% 95% 95%

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Cancer waits against targets – composite

All achieved All achieved All achieved

Access and waiting times

Referral to Treatment: patients admitted treated within 18 weeks

92.5% 91% (national

target 90%) 90%

Referral to Treatment: non admitted patients treated within 18 weeks

98.6% 98% (national

target 95%) 98%

Referral to Treatment: incomplete pathways within 18 weeks

95.4% 95% (national

target 92%) 95%

Choose & Book slot availability 11% 10% 10%

Outcome 1.4 - Excellent feedback from patients, staff and stakeholders

Patient experience

‘Friends and Family Test' (FFT) - net promoter score - based on percentage of patients recommending hospital ward as place of care to family and friends

22 30 35

Mixed sex accommodation 6 breaches Zero breaches Zero breaches

Staff Experience

Friends and Family Test' (FFT) – based on the number of staff that would recommend the trust as a place to work and receive treatment

3.19

3.65 (this would be a stretch challenge)

3.81 (takes us into the top 20%based on current figures)

Patient Environment

Annual Patient Led Assessment of the Care Environment (PLACE) score

Cleanliness – 94.1% Food – 82.9% Privacy, dignity and wellbeing – 87.1% Facilities – 78.7%

2013/14 national averages: Cleanliness – 95.7 Food – 85.4% Privacy, dignity and wellbeing – 88.9% Facilities – 88.8%

Half way to 2013/14 national upper quartile: Cleanliness – 97.6% Food – 89.1% Privacy, dignity and wellbeing – 91.0% Facilities – 90.8%

Readmission rates

Net Emergency Readmissions within 28 days

5.0% 4.8% 4.6%

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5 STRATEGIC AIM TWO – PEOPLE

We will make best use of our expert skills and capabilities, invest in education, training and research to continually improve our practice, and offer fulfilling and valued careers.

5.1.1 There is an evidence base correlating highly trained, motivated, well managed and engaged staff with quality of patient care and lower mortality rates. Investing in leadership, training, health and well-being, effective communication, with opportunities to be involved in research and education, will translate into a more motivated and effective workforce more likely to provide excellent patient experience

5.1.2 The Trust’s Our People Strategy sets out the proposed commitments made by the Trust Board. The strategy is managed through the Our People Programme Group and co-ordinates a whole systems approach to delivering our business through an effective, efficient, empowered and engaged workforce.

5.1.3 Effective deployment of our current staff establishment is under review. This is supported particularly through on-going analysis of demand for staff, both temporary and permanent, and work within the divisions to establish staff requirements for each ward and service area. The Nursing and Midwifery Group has been exploring the existing establishment ratios alongside data provided by the ‘Safer Nursing Care Tool’ and ‘Birthrate Plus’ to get a clear understanding of staff requirements.

5.1.4 Over the next two years the organisation will continue to strengthen the integration of workforce, finance and service provision to maximise productivity. The current business planning process requires Divisions and Specialties to detail the workforce changes required to deliver their proposed plans. This involves setting out the requirements for skill mix, role re-design and education commissioning requirements for the establishment of new roles.

5.1.5 Of particular note is the increasing Band 4 workforce. We will deliver Higher Apprenticeships from Autumn 2014 with a focus on raising the skills and competencies across our Band 1-4 workforce through the development of a clear career pathway, with a strengthened approach to maternity support workers and assistant practitioners.

5.1.6 Extending the nursing and allied health professional roles across the organisation will also deliver quality improvements across all divisions. The Workforce and Business

Outcomes by 2016:

Inspirational multi-disciplinary leadership and effective management of all of our services

A resilient workforce that is proud to work for Royal Cornwall Hospitals Trust and effective and efficient deployment of our expert skills and capabilities

A thriving research, improvement and innovation portfolio that informs and improves patient outcomes

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Intelligence Lead supports the specialty leads in considering the plans and provides training support in workforce planning to strengthen the divisional expertise. This ensures that the activity is underpinned by organisational and divisional plans to commission development as required.

5.1.7 Recent national enquiries and reports such as those by Francis, Keogh and Berwick may have an impact on the current establishment of staff. These remain under review with a firm focus on quality and safety. The workforce and service plans are risk assessed in line with recommendations, focussing on the right staff, in the right place, at the right time – every time.

5.1.8 Over the next year the largest impact on workforce may be the Hotel Services project which could involve staff transfers in a TUPE arrangement with a commercial facilities provider.

5.1.9 Continuing to drive efficiency through new ways of working and new service procurement (i.e. Pathology) will also have an effect on the deployment of our staff. Adopting alternative management methodologies such as LEAN and the implementation of technological advances outlined in our Health Informatics Strategy is likely to see changes in both the clinical setting and the Support Services Directorates.

5.2 NATIONAL STAFF SURVEY

5.2.1 We know that our staff feel that their working experience at the Trust could be improved based on the findings from the National Staff Survey and internal local staff survey activity. However, over the last 2 years we have seen sustained, albeit fragile, improvements in a number of staff satisfaction scores.

5.2.2 We have invested in, and implemented the ‘Listening into Action’ methodology for improved engagement. We will continue to build on the improvements achieved so far and will utilise the 2013 National Staff Survey to develop further interventions for improved staff experience.

5.2.3 In previous years, the Trust has had challenging results from the NHS Staff Survey. The 2013 survey shows slight improvement in staff engagement in the survey at 49% versus 48%. The 2013 results are demonstrating some ‘green shoots’ of improvement. There have been improvements across 19 of the metrics measured (5 others have remained static and 5 declined). Also the percentage of staff who would recommend the Trust as a place to work or receive treatment has improved.

5.2.4 However, the Trust remains in the bottom 20% of all acute trusts nationally for its staff scores. We have plans in place to further analyse and disseminate the staff survey results across three defined levels: organisational, divisional and across staff groups. The intention is to develop specific action plans for each of the levels building on best practice experiences. Full data analysis and action plans are being considered at the Trust Board in March 2014.

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5.3 OUR PEOPLE STRATEGY

5.3.1 In order to provide a strategic focus for staff engagement and development within the Trust, the ‘Our People’ Strategy has been developed. The aim is to:

5.3.2 The strategy is based on a whole systems approach, ensuring people issues are at the core of the Trust’s business planning.

5.3.3 The delivery of this strategy is through a Programme Management Board which will has an Executive lead, clinical and non-clinical representation, staff-side and governor as well as project management and HR representation. ‘Our People’ Strategy focuses on:

Deliver high quality patient outcomes through effective and efficient people who 

are engaged and enabled. 

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5.3.4 The Strategy gives measurable key performance indicators and the 2018 targets, some of which are detailed below as part of the ‘Measuring Strategic Aim Two’ section.

5.4 WORKFORCE PLANNING

5.4.1 All divisions have reviewed their workforce resourcing requirements with a view to ensuring that they have capacity and capability to meet the current and future two years activity and saving plan expectations.

5.4.2 This has been a thorough exercise of looking at upcoming retirements, skill mix reviews and development of new practitioner roles. Divisions have needed to demonstrate cost efficiencies and their ability to maintain quality of service.

5.4.3 The Trust has a strategy to increase the proportion of qualified nurses, to move to 65:35, (qualified being 65%). The role of Assistant Practitioner will be supported by learning and development with a lead-in time so the cost of investing in this new ratio will be around £0.65M for the first two years, reducing to around £0.25M thereafter.

5.4.4 The financial plan sets out the impact on workforce numbers with regard to identified savings schemes, cost pressures and potential investments.

5.4.5 The net change to workforce numbers will depend on the balance of affordable investment generated after delivery efficiency gains.

5.4.6 Key issues to address include:

Implementation and affordability of 65:35 nurse to support staff ratio

Improving attendance; reducing stress at work and related sickness

Potential movement to new providers for around 500 staff

Ability to improve staff morale in the context of the financial challenges

5.5 RESEARCH, DEVELOPMENT AND INNOVATION

5.5.1 As part of delivering strategic aims one and two, focussing on our quality and our people, the aim for the Trust as part of its Research, Development and Innovation (RD&I) plan is:

5.5.2 A number of priorities have been defined to measure the implementation of the RD&I plan:

To become an organisation whose operation is underpinned by evidence, 

research and innovation, to deliver the highest standards of clinical care. 

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RD&I Service pledges

To increase numbers recruited to all studies to 2500 in 2014/15

To increase our commercial portfolio - 20 new studies to be added to the current 75 in 2014/15

To generate and support local research ideas to ensure a minimum 3 grant applications in 2014/15 rising to 5 in 2015/16

To enhance study performance in achieving 80% of studies open and recruiting in 45 days from initial application

Communication strategy – increased engagement with interested parties via dedicated. Measured by feedback on quality of communications.

Develop the structure, efficiency and support within the delivery team. Measured by increased recruitment and stable and retained staff base.

Ensure effective and robust governance oversight of studies. Measured by positive Medicine and Healthcare Products Regulation Agency inspection

5.6 ACADEMIC HEALTH SCIENCE NETWORK

5.6.1 Following the publication of the Department of Health’s ‘Innovation Health and Wealth’9 in December 2011 the concept of Academic Health Science Networks has been formed as part of transforming health outcomes and the delivery of healthcare in England. This is to be achieved by bringing together the local NHS, higher education institutions and industry to focus on improving the identification, adoption and spread of innovative health care across a defined geographic footprint.

5.6.2 The Trust has been an active participant in establishing the Peninsula Academic Health Science Network (AHSN). The AHSN aims to facilitate the development of close and effective working relationships between health organisations across the peninsula and most critically with industry and pharmaceuticals. As part of the initial application, there was a commitment to a number of objectives:

Transforming research delivery

Service improvement – expanding the use of innovation and best practice

Creating wealth

Building capacity – education and training and information and informatics

Communications and engagement

5.6.3 We continue to participate in events organised by AHSN and endeavour to contribute to the successful achievement of the objectives.  

                                                            9 Innovation Health and Wealth’9 published in December 2011

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5.7 MEASURING STRATEGIC AIM TWO - PEOPLE

Category Performance Indicator 2013/14 Actual 2014/15 Target 2015/16 Target

People – We will make best use of our expert skills and capabilities, invest in education, training and research to continually improve our practice, and ensure all staff have fulfilling and valued careers.

Outcome 2.1 - Inspirational multi-disciplinary leadership and effective management of all of our services

Leadership and management

% staff reporting good communication between senior managers and staff

21% 30% 35% (into top 20%)

Leadership and management

% staff who feel supported by their immediate managers

3.48 3.66 (as per quality accounts

3.71

Outcome 2.2 - A resilient workforce that is proud to work for Royal Cornwall Hospitals Trust and effective and efficient deployment of our expert skills and capabilities

Workforce Total staffing 5,018 4,498 4,487

Appraisal Proportion of staff appraisals in last 12 months (of eligible)

82% 89% (top 20%

performer) 100%

Sickness / absence % of contracted staff wte lost to sickness

4.27% 3.75% 3.50%

Staff Engagement % of staff who complete the NHS staff survey

49% 60% 60%

Staff morale % of staff who recommend RCHT as a place to work

40% 45% 50%

Staff morale % of staff who recommend RCHT to family and friends

42% 50% 64%

Staff education and training

% of staff who say that appraisal helps them do their job better

60% 65% 70%

Staff education and training

% staff who say that they have access to job relevant training

77% 79% (takes us into median)

83% (takes us into the top 20% performers

Outcome 2.3 - A thriving research, improvement and innovation portfolio that informs and improves patient outcomes

Research activity To increase numbers recruited to all studies

1600 2500 2600

To increase our commercial portfolio

New studies commenced 75 95 95

Improvement study performance

% of studies open and recruiting in 45 days from initial application

80% 85% 85%

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6 STRATEGIC AIM THREE – PARTNERSHIP

We will collaborate and innovate with our partners to deliver integrated, seamless and patient-focussed pathways of care and be the provider of choice in Cornwall.

6.1 CONTEXT

6.1.1 The vision of integrated care is being developed and evaluated by NHS Kernow, and sets the context for partnership working to ensure improvements in the quality of care. The aim is to provide as much of each pathway as close to patients’ homes as possible, as well as living within the tight public finance constraints.

6.1.2 There are new proposals, describing the continued development of primary care (Federations) being the hub of health and social care activity which is predicated upon the expansion of primary and community care, through the transfer of resource from the acute sector. This implicitly assumes also that the transfer will allow the acute sector to accommodate demographic growth net of a reduction in demand. The Trust will engage constructively with patients and commissioners to redesign the whole system, but will also need to ensure the core acute services are clinically and financially stable.

6.1.3 We are working across the health and social system to ensure that patients receive quality services with no visible gaps arising from organisational transfers. Our ambition is to further develop and extend integrated care models and we are pro-active in establishing dialogue with NHS Kernow CCG and other NHS partners.

6.1.4 All of our services would benefit from a focus on integration and are not limited to our services delivered in buildings. We are passionate about improving care pathways and recognise that a key area is supporting patients with long term conditions.

6.2 PATHWAY CHANGES AND MARKET OPPORTUNITIES

6.2.1 NHS Kernow have set out intentions for Elective Community Services, (for example Gynaecology, Dermatology) and, linked to this, the possibility of a different form of tender for the ISTC at Bodmin. The Trust must respond to these and also continue to work with the Referral Management Service (RMS) in order to ensure that our referral

Outcomes by 2016:

New service models aligned with NHS Kernow’s integrated vision for Health and Social Care

Create a new service offer in East Cornwall in response to the ISTC contract, and achievement of growth under AQP

Strengthened clinical networks, new joint care models and partnership ventures to underpin the viability of services in Cornwall and Isles of Scilly

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criteria reflect agreed practice and ensure that patients get access to the right service on the first occasion.

6.2.2 Whilst non-elective demand held steady in the early part of 2013/14, there have been increases in the latter period and overall are significantly higher than NHS Kernow predicted. NHS Kernow is working with the whole health and social care system to identify a means of reducing demand on the Trust. However, the age demographics indicate that with a backdrop of an increasing size and ageing population, there remains a risk that activity could continue to increase.

6.2.3 An analysis of the growth of population and age range for the next five years together with current admission profiles using most common diagnosis, current length of stay is being progressed so that the pathway models and the bed base can be agreed and planned accordingly.

6.2.4 NHS Kernow have also set out specific pathway priorities with respect to urgent care – around Frail Elderly, Chest Pain, Respiratory and through these intend to reshape/re-size acute core services, with more intervention being made in community settings. We will need to be adaptive in our consideration of these challenges, to eliminate unnecessary admissions, offer effective treatment and look to minimise impacts from a business perspective.

6.2.5 Pathway work is also a critical part of service redesign in Surgery (e.g. through the Enhanced Recovery model) and in Children’s Services. Each Division is responsible for the adoption of best practice and engagement with patients and partners to improve outcomes for patients.

6.3 WHOLE SYSTEMS GOVERNANCE

6.3.1 The Trust actively engages in the local examples of partnership working and integrated planning. These include the Leadership Summit, Whole System Delivery Group and Public Sector Group. These aim to bring together key partners in developing innovative solutions to their shared agenda of providing high quality and sustainable services to the people of Cornwall and the Isles of Scilly.

6.3.2 The Leadership Summit and Whole System Delivery Group (WSDG) includes membership from all the key partners in the health and social care community locally and provides a forum to identify and work on issues on organisations’ common agendas.

6.3.3 The Group is important in helping to break down organisational barriers and in developing working relationships in recognition that all local public sector bodies face significant challenges in delivering effective services in a financially constrained environment.

6.3.4 The Public Sector Group has a wider membership than the WSDG encompassing not only the health and social care community but seeking to engage all representatives of the public sector in Cornwall and the Isles of Scilly in joint analysis, planning and, where appropriate, delivery.

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6.4 BETTER CARE FUND

6.4.1 The Better Care fund (BCF) is a new initiative announced by the Government in June 2013 with the aim of supporting transformation in integrated health and social care. The Fund is seen as an important enabler to take the integration agenda forward at scale and pace, acting as a catalyst for change.

6.4.2 The BCF is a single pooled budget nationally of £1.1BN in 2014/15 rising to £3.8BN in 2015/16. It is established to support health and social care services to work more closely together in local areas. In Cornwall and Isles of Scilly this represents a revenue position of £12.8M in 2014/15 rising to £42.5M in 2015/16. The financial impact of the BCF on the Trust’s finances forms part of the commissioning and contracting negotiations.

6.4.3 The main financial impact on the Trust is expected to occur in 2015/16 as funding is redirected by NHS Kernow to support social care activities which have health benefit with an expectation of reduced demand in the acute sector.

6.4.4 There are six national deliverables associated with the fund which are represented in the local BCF plan which was presented to Cornwall Council’s Health and Wellbeing Board on 3 April:

6.4.5 The final point in the list re-emphasises the need for the Trust to continue to be involved in the discussions on developing the BCF plan for Cornwall. There is a requirement for NHS Kernow and Cornwall Council (as host of the Health and Wellbeing Board) to engage all providers, both NHS and social care, likely to be affected by the fund in order to achieve the best outcomes for local people. That is, providers, CCGs and councils are expected to develop a shared view of the future and how it will be implemented.

6.5 INTERGTRATED CARE PIONEER: LIVING WELL

6.5.1 Nationally 14 ‘Integration Pioneers’, of which Cornwall is one, have been approved by Government with the aim of transforming the way health and care is delivered by providing better support and earlier treatment in the community to prevent people needing emergency care in hospital or care homes.

6.5.2 Cornwall and Isles of Scilly as one of the 14 Pioneers, has a project in the Penwith area which builds on a related the, the Newquay Pathfinder. Given the whole systems impact of the project, the Trust is actively engaged in working as part of the project team considering the issues and responses to this project. The project is at a relatively early

Plans to be jointly agreed

Protection for social care services

Provide 7 day health and social care services

Better data sharing

Joint approach to care planning

Agreement on the consequential impact in the acute sector

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stage but potentially has important impacts on the future of health and care provision models.

6.5.3 The key outcomes are to improve quality, experience and cost effectiveness across the whole health and social care chain. It also encompasses the integration of Commissioning; sharing of information, and the empowerment of local clinical teams, GPs and public, to redesign services, access support earlier and this improve health and wellbeing.

6.5.4 During the first six months of 2014/15 detailed modelling and planning will be undertaken to evaluate the potential costs and benefits of the integrated model, alongside the other elements of NHS Kernow’s vision e.g. Urgent Care system, GP Federations/localities, enhanced community services. This work will be critical and inform the County’s response to the challenges of 2015/16 when the full impact of the Better Care Fund and other financial constraints are set to hit the resource quantum.

6.6 GP ENGAGEMENT

6.6.1 We have made significant progress in building relationships with GPs as commissioners, as providers of primary care, and also as our customers. The aim is to continue to build on this relationship by linking with each of the ten localities within NHS Kernow, attend their meetings and receive feedback on our service provision first hand. We will continue to hold GP engagement events, but also explore opportunities for more direct GP/Consultant dialogue.

6.6.2 Common themes arising in the locality meetings are ways to improve availability of information about our services, negotiating requests for service and wanting timely access to patient information as part of the pathway e.g. results. Following a successful GP engagement event in November 2013, the Local Medical Committee is now looking to convene regular meetings with educational content between GPs and Consultants.

6.6.3 Overall, there is recognition that we need to improve the service information available to GPs and patients as part of ensuring clear understanding of our service offerings.

6.6.4 GPs are likely to form Federations in 2014/15 and this presents opportunities to develop more direct service agreements, provide better engagement and be more responsive to their needs. This is counter balanced though by the potential for such Federations to compete for existing market share – hence the importance of positive relationships and excellent services.

6.7 RESPONDING TO THE MARKET

6.7.1 Four services currently offered by RCHT are being opened up to the market via Any Qualified Provider (AQP). This presents both opportunities and a service challenge to Audiology, Clinical Imaging and Therapies departments. Clear service offerings are in place and widely promoted, in order to retain our market share as a minimum requirement. There is also the potential to explore commercial partnership in order to mitigate threats from new competitors e.g. other imaging.

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6.7.2 However, any growth needs to be set in the context of the contractual structure to ensure that the additional income opportunity will support the required expenditure investment both from a capital and revenue perspective.

6.7.3 Relatively untapped markets are still available ranging from preventative health care services through to very specialist tertiary care. This spectrum is constantly changing, and RCHT recognises the need to be flexible and outward looking with regard to the scope of the service offer and its competitive positioning. Much of this is reliant on developing its relationship marketing and to this end, it is critical that we empower our staff, especially clinicians to be ambassadors for our services and build relationships directly with GPs as our key customers. As already, indicated above, GP engagement will continue to be a high priority for 2014/15 and beyond.

6.7.4 Additionally Cornwall Council, in its public health role, may tender for Sexual Health Services currently provided by the Trust. The timing of the tender is not known at this stage. We have developed a project team to develop our bid for this work, including clinical representation. To be effective the Trust recognises the need to develop its expertise in bid construction.

6.7.5 In addition to the potential to outsource Hotel Services further partnerships are could occur with the private and public sectors to leverage existing and growing commercial capability and capacity.

6.7.6 The impact of a significant segment of RCHT's current portfolio and staff base being managed as a third party contract with strategic suppliers would have major consequences for the organisational design and resource planning of the Trust, with a growing requirement for current procurement and contract management/demand management expertise. This has been recognised in the creation of a dedicated Market Test team, but will require further consideration and expansion in 2014/15.

6.8 MEASURING STRATEGIC AIM THREE - PARTNERSHIP

Category Performance Indicator 2013/14 Actual 2014/15 Target 2015/16 Target

Partnership – We will collaborate and innovate with our partners to deliver integrated, seamless and patient-focussed pathways of care and be the provider of choice in Cornwall.

Outcome 3.1 - New service models aligned with NHS Kernow’s integrated vision for health and social care

Create new models in line with Elective Adult Community Services and Children’s integrated Care

Streamlined pathways, and more accessible services models – (Ophthalmology, Gynaecology Dermatology, Neurology, Rheumatology, Urology) and Integrated Children’s Services

n/a Pathways and outpatient modelsagreed and in place

Quality and experience outcomes (to be agreed with NHS Kernow)

Improved acute , urgent care pathways Delayed transfers of care

retained at a minimal level 3.5%

3.5% or lower to be agreed with NHS Kernow

3.5% or lower to be agreed with NHS Kernow

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Category Performance Indicator 2013/14 Actual 2014/15 Target 2015/16 Target

Avoid unnecessary admissions and reduce length of stay for chest pain, heart failure and pneumonia

n/a

Audited evidence of compliance and outcomes

Audited evidence of compliance and outcomes

Achieve national admission and surgical rates for Orthopaedics, without compromise to outcomes

Comply with changes to MSK pathways

Implement peer review with commissioners

Lead GP education to improve referral quality

n/a To be agreed with NHSK

To be agreed with NHSK

Outcome 3.2 – Create a new service offer in East Cornwall in response to the ISTC contract, and achievement of growth under AQP

Achieve growth under AQP/Choice

Market share increase Maintained market position in context of referral growth

5% market share growth at profit

8% market share growth at profit

Respond to Commissioner Market intentions - ISTC contract, and Sexual Health

Propose creative solution for East offer, linked to ISTC , including partnership with commercial provider

n/a Successful outcome to tender process

Service models established and effective –KPIs to be determined

Prepare submission exploiting technology , offering new models and possible third sector partnership for Sexual Health

n/a

Successful outcome to tender process

Service models established and effective –KPIs to be determined

Outcome 3.3 - Strengthened clinical networks, new joint care models and partnership ventures to underpin the viability of services in Cornwall and Isles of Scilly

Review Specialist services and networks to achieve sustainable access to care in Cornwall

New, viable model for Vascular Surgery

Respond to National and local Urgent Care redesign

Exploit opportunities with/without Plymouth and RDE - Pathology , vascular, non-clinical services , plastics

n/a Compliance / with derogation:

Clinically and financially viable service models

Expanded offer in Cornwall

Will be dependent upon outcomes in 14/15

Market test programme

Deliver the market test programme (clinical and non clinical) – e.g. Hotel Services, Pathology, Paying Patients.

Progressed Hotel Services to plan. Scanning project stood down.

Achieve agreed programme milestones

Achieve agreed project outcomes

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7 STRATEGIC AIM FOUR - RESOURCES

We will be financially sustainable and make efficient use of our resources to provide safe and welcoming environments, modern equipment, facilities and technology, to underpin service transformation.

7.1 FINANCIAL PLANNING

7.1.1 Our financial plan for 2014/15 and 2015/16 is based on achieving a surplus of £3.9m, part of which will be used to repay the Trust’s debt and the remainder to improve liquidity and invest in our services. Our plan is fully risk assessed and enables the Trust to achieve a level 4 financial risk rating under Monitor’s rating arrangements, reducing to a level 3 in 2015/16 following additional borrowing for capital purposes.

7.1.2 The achievement of these surplus levels will be challenging. NHS organisations throughout the country face unprecedented requirements to save money and improve services, and this has continued for several years. During 2015/16, the introduction of the Better Care Fund will look to move income and activity away from the acute sector and could have a material impact on the Trust’s cost base. The Trust continues to work with its partners to help develop, challenge and deliver services changes to help achieve the vision of its commissioners.

7.1.3 During 2014/15 the Trust will need to make savings of £14m in order to achieve its financial targets. Over the past 4 years the Trust has already made savings in excess of £50m.

7.1.4 Nonetheless, the Trust has well established arrangements for identifying opportunities for savings and ensuring that these do not impact on quality and patient safety. This is achieved through review of all savings schemes by the Nurse Executive and Medical Director.

Outcomes by 2016:

Achieve planned surpluses of £3.9m each year

Best in class productivity and efficiency standards , delivered through quality assured CIPs

Completion of our sites development plan phase 1, and achievement of expected patient and business benefits

Fully utilised and robust, electronic patient care and management systems, supporting high quality, efficient care

Successful work with partners to achieve our sustainability goals adding value to the economic health of Cornwall and Isles of Scilly

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7.1.5 Long term financial planning is well established within the Trust and the key financial values in the 2014/15 financial plan are consistent with the Trust’s long term financial plan financial plan. This includes scenario based planning to develop alternative ways to achieve financial targets. A full risk assessment is also carried out on the 2014/15 financial plan to identify key risks and mitigating actions.

7.1.6 The 2014/15 financial plan and capital programme was agreed on 27 March 2014. This includes an explanation of financial planning assumptions on both income and expenditure, details of expected workforce changes, a 2 year capital programme (a 15 year programme is under development) and a risk based analysis of the savings in place to ensure delivery of our plan. Appendix 1 sets out the financial plan for 2014/15 in more detail.

2015-16

7.1.7 The additional level of savings required for 2015-16 is determined by the same factors for 2014-15 but add cumulatively to the savings challenge for 2014-15.

7.1.8 Indications are that Trusts will be expected to deliver a minimum 4.5% in efficiencies during this year. This equates to c£15.8m. Within this value c£5m relates to the cost of pay awards and incremental drift expected as part of current pay award assumptions.

7.1.9 In addition, the financial plans prepared by Divisions for 2014-15 also look forward to 2015-16, although additional investments of only c£1m have been identified. This is expected to increase during the 2015-16 budget setting round although, assuming that the baseline budget for 2014-15 is deliverable and delivered, there should be a significantly reduced impact as the 2015-16 budget will not have to be rebased for non-delivery of CIP and baseline pressures.

7.1.10 The impact of the Better Care Fund in Cornwall will determine the level of funds for NHS Kernow. This will place additional pressure on the need to reduce acute healthcare spend, although the contract type agreed to in 2015-16 will ultimately determine how RCHT is affected by the Better Care Fund.

7.1.11 The LTFM will be updated with 2014-15 financial plan and the 2013-14 year end outturn values and included in the Trust’s 5 year business plan to be produced by 21 June 2014.

7.2 INCOME

7.2.1 Our total income forecast for 2014/15 is £329m, of which £229m relates to services commissioned from NHS Kernow and £49m relates to services commissioned from NHS Commissioning Board. The remaining income relates to education and training, services provided to the local authority and Peninsula Community Health and other income.

7.2.2 The Trust continues to work with NHS Kernow to identify and deliver service changes to reduce the volumes of emergency attendances and inpatient admissions, and to ensure the clinical and financial sustainability of services going forward. CQUNS will continue to have a value of 2.5% on top of the contract value for 2014/15.

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7.3 EXPENDITURE AND SAVINGS

7.3.1 Our financial plan shows total expenditure of £325m of which £305m relates to operating expenses and £20m relates to depreciation and financing costs.

7.3.2 Cost pressures and potential investments totalling £17m have been identified for 2014/15 and incorporated into the financial plan. With projected increases in income, a savings plan of £14m is required and this is in line with the LTFM and matches the savings identified through the 2018 programme. The savings level is expected to be around £16m in 2015/16.

7.3.3 However, it should be noted that this represents the internal efficiency challenge only. Any change in income levels as a result of the impact of the Better Care Fund will increase the savings requirement and level of challenge to the Trust.

7.3.4 The plan allows for £1.5m of discretionary investments to be funded. Should additional income be generated over expected levels, further investment may be possible. The allocation of funds for discretionary investments will be made based on the Trust’s and divisional priorities, providing clear links between financial investment and delivery of the Trust’s business plan.

7.3.5 A summary of Income and expenditure is provided below.

7.4 PROJECTED ACTIVITY, DEMAND AND CAPACITY

7.4.1 The contract with NHS Kernow drives the majority of our service demand, however the detail is yet to be finalised at the time of writing The activity plan with commissioners is based on forecast outturn adjusted for service developments, demographic growth, specialty-specific growth, repatriations, the effects of this year’s activity on waiting lists,

2013-14 2014-15 £ change % change£000 £000 £000 %

INCOMENHS Kernow 223,930 229,735 5,805 2.6%Specialised Commissioning 47,282 48,482 1,200 2.5%Area Team 9,464 10,460 996 10.5%NCAs 4,767 4,424 (343) -7.2%Cornwall Council 3,040 3,054 14 0.5%Services provided 8,753 8,753 0 0.0%Other income 24,752 24,293 (459) -1.9%Interest receivable 98 98 0 0.0%Total income 322,087 329,300 7,213 2.2%

EXPENDITUREPay (202,559) (209,191) (6,633) 3.3%Non-pay (96,429) (97,367) (938) 1.0%Capital charges (19,199) (18,841) 358 -1.9%Total expenditure (318,187) (325,400) (7,213) 2.3%

Surplus 3,900 3,900 0 0.0%

Income and Expenditure

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and other changes caused by non-recurrent elements in the forecast outturn. This has been completed as usual in close liaison with the clinical divisions and all Specialty Directors have also been involved in setting the current proposed plans for next year. The Trust has a robust methodology for this and a clear audit trail setting out the building blocks of the plan.

7.4.2 The Trust has noted deterioration in our productivity in 2013/14, and this, combined with

potential growth, presents significant capacity challenges. These are detailed, and worked through in the Specialty plans, and also will be addressed through three major productivity programmes for Theatres, Beds, and Outpatients. Notwithstanding this, close performance management will be required in high risk specialties including: Orthopaedics, Ophthalmology, Gynaecology, Dermatology, Cardiology and supporting Diagnostic services. This is intrinsically linked to the need to make rapid progress to recover our RTT to the level of half a week’s backlog (250 patients), and ensure we progress to more challenging targets, earlier in the pathway.

7.4.3 The table below summarises activity, prior to contract completion.

7.5 CAPITAL EXPENDITURE

7.5.1 A capital programme covering the period 2014/15 to 2015/16 has been agreed. For 2014/15 total capital expenditure is planned to be £21.7m and this enables considerable investment in the Trust’s estate, medical capital equipment and information technology infrastructure, linked to the delivery of the Health Informatics Strategy. The Trust intends to borrow £4.5m in 2014/15 to ensure that investment in medical equipment and the IT infrastructure is at the appropriate level, and further borrowing may be undertaken as the benefits of potential projects are clarified.

Elective (note 1) 61,341 63,676 65,456 1,780 2.8%Non Elective 35,232 38,266 37,588 -678 -1.8%Outpatients 464,052 480,526 497,203 16,677 3.5%A&E 65,634 65,497 66,171 674 1.0%Maternity pathways 16799 15,039 15,541 502 3.3%NHS Cornwall (total units) 643,058 663,004 681,959Note 1 - includes increase of 677 spells (1% of 2.8% increase) re waiting list review

Year on year

increase against FOT (%)

ActivityActivity 2013-14

Contract

Activity 2013-14

FOT

Activity 2014-15

Contract

Year on year

increase against

FOT

Capital plan highlights:             

Estates                                    £3.5m      including £1.4m fire precautions 

Health informatics                £5.4m      including platform refresh £2.0m and    

                                                      PAS £0.7m 

Medical equipment              £6.5m      including replacement LINAC £2.1m and 3rd  

                                     MRI £1.5m 

Clinical Site Development   £6.3m      including reprovision of Endoscopy and 

                Urology £2.3m and Maternity reconfiguration £1.9m 

Total          £21.7m   

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7.5.2 The Trust is also mid-way through the development of an ambitious 15 year capital programme which is designed to ensure that key items of equipment are replaced at the right time, and that the Trust can deliver on the remaining phases of its successful Clinical Site Development Plan (CSDP)

7.5.3 Once we achieve Foundation Trust status, the freedoms to invest further in property, plant and equipment will be reviewed and the Board will have the opportunity to consider how elements of the 15 year capital programme can be accelerated.

7.6 COST IMPROVEMENT PROGRAMME

7.6.1 The Trust has developed the 2018 project programme which has provided a strong basis for the development of a rolling Cost Improvement Programme (CIP) with schemes being identified since June 2012. Each CIP scheme has had a full risk and quality impact assessment at both divisional and corporate level. The Programme spans five years, however the information below is focussed on 2014/15 to 2015/16. The Programme will deliver financial savings and more importantly, will deliver quality benefits through service redesign, and improved patient experience. The themes addressed through the Programme include:

Pathways Improvement (including commissioner led pathway changes) Workforce productivity Efficient use of the theatre network Procurement and non-pay CSDP, Estates and Facilities, including design of outpatient services Income generation Technology enabled redesign

7.6.2 Pathways improvement – each division is developing plans to focus on improvements which will lead to reduced admissions, more productive patient flow through the hospital and improved quality of care and experience for patients. At the time of working there is considerable risk with Medical Strategy, and is therefore the subject of priority work.

7.6.3 Workforce Productivity – each division reviews their workforce plans on a regular basis to ensure the appropriate resources are in the right areas and providing the clinical support to maximise opportunities for clinical excellence and increase the flexibility of the Trust delivery model. These workforce plans encompass national plans for local services to move to 7 day working as a norm and maximise efficiency and sustainability. The Board previously agreed to re-profile the CIP Scheme in relation to teams and conditions of employment whilst further work is undertaken. This has reduced the value in 2014/15.

7.6.4 Efficient use of the theatre network – Plans are in place to ensure that the Trust’s theatre operate as efficiently and effectively as possible, taking maximum benefit for this valuable resource and improving patient flow. Productivity has reduced in 2013/14; therefore recovering to this level is the first priority.

7.6.5 Procurement and non-pay – in line with Trust Board’s direction, savings should first be exhausted from procurement and non-pay opportunities. These opportunities include:

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the implementation of electronic prescribing, enabling greater visibility of pharmacy expenditure, reduce spend waste and errors

the implementation of digital dictation trust wide the implementation of GP ordercomms Improved management of contracts

7.6.6 CSDP, Estates and Facilities, including outpatient services – The Clinical Site Development Plan and site rationalisation plan seeks to:

underpin improvement to the quality and efficiency of services on our sites improve patient flow, improving clinical efficiency and patient experience reduce the footprint of the organisation as a whole, by increasing space utilisation

and reducing overhead costs. Ensure that outpatient services are designed to maximise efficiency and use

technology to provide an optimum service to patients.

7.6.7 Technology enabled redesign – The Informatics Strategy outlines an ambitious future moving towards a paper light organisation. The replacement for the Patient Administration System in 2015/16 will provide significant opportunities for service redesign and productivity improvement. Individual divisions have identified schemes which make use of innovative developments in technology based solutions such as digital dictation, and electronic prescribing.

7.6.8 Income generation – Schemes to support this strategic theme include increasing income via adopting best practice, ensuring delivery of CQUIN, making RCHT the ‘first choice’ provider and maximising opportunities paying patients can offer the Trust

7.6.9 Other savings schemes include:

Ensuring that all back-office services offer best value for money Maximise opportunities in Pharmacy Services to maximise efficiencies, cost

savings and reduce wastage. Redesign and procure Pathology Order Comms Systems across GPs and other

internal services to ensure consistency, maximise efficiencies and reduce duplication.

Introduce digital dictation systems across the Trust.

7.6.10 Each of the CIP schemes has been subject to a detailed risk assessment which will be monitored in year. This risk assessment includes a quality impact assessment for each scheme which is reviewed by both the Medical Director and Nurse Executive in the Star Chamber. The position at the date of preparing this plan is set out in the table below.

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7.6.11 It is important to note that whilst some schemes have been risk assessed as amber or red, they remain valid and deliverable schemes and so form part of the Trust’s financial plan. The risk related to each will continue to be assessed and Divisions and departments will be expected to replace any scheme where there is a risk of non-delivery.

7.7 SUSTAINABLE DEVELOPMENT

7.7.1 The Trust has an obligation to achieve the carbon reduction targets as set out by the UK Government under the Climate Change Act. The Trust has a Sustainable Development Management Plan (SDMP) in place and is working to raise awareness of sustainable development at all levels in our organisation so that staff are empowered to feed into the development of our services.

7.7.2 The Board recognises the importance of this agenda and that moving towards a more sustainable low carbon future will provide healthcare and wider social benefits. The Trust’s SDMP focuses three core areas of impact: financial, environmental and social.

7.7.3 The SDMP provides the delivery mechanisms for measuring performance, such as reducing carbon emissions and managing carbon reduction effectively as part of core business and delivery of our services. To assist us in fulfilling our carbon reduction requirements and promoting awareness the SDMP provides the framework for driving forward sustainable development by;

Capitalising on the complementary nature of sustainability and health and well-being

Harnessing the willingness and commitment of NHS organisations and staff to act now

Meeting the requirements of the NHS Carbon Reduction Strategy (CRS) which incorporates targets under the Climate Change Act

Improving financial resources through cost savings achieved by carbon efficiency

Demonstrating the Trust’s commitment to raising the quality and sustainability of its health buildings and spaces

7.7.4 The SDMP will be implemented by the Sustainable Development Management Group which will develop appropriate underpinning work streams and action plans across

Division

Original 

14/15 CIP 

target 

Revised 

14/15 CIP 

target

Green rated 

schemes

Amber rated 

schemes

Red rated 

schemes

£000 £000 £000 £000 £000

Corporate 3505 168 64 0 104

CITS 171 2262 1647 615 0

Clinical Support Services and Cancer 2210 2652 1084 739 830

Medicine 1583 2805 612 150 2043

Theatres, Anaesthetics, Surgery, Trauma and Orthopaedics 2666 2989 388 823 1778

Womens and Childerens 722 1207 422 299 486

Trustwide 2155 1920 720 1200 0

Grand Total £13,012 £14,003 £4,937 £3,825 £5,241

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transport, procurement, facilities management, energy management, waste, workforce and building design and to monitor implementation.

7.7.5 Additionally the Trust has a plan to complete a programme of works to improve fire safety measures within the Trust's buildings and ensure compliance against the Regulatory Reform (Fire Safety) Order. We will carry out an external audit of fire safety management using the Trust's Authorised Engineers (Fire) to determine compliance against Health Technical Memorandum 05-01 : Managing Healthcare Fire Safety.

7.7.6 We will improve health and safety management and awareness across the Trust by implementing a programme of improvement actions and measuring performance via an internal audit review.

7.8 MEASURING STRATEGIC AIM FOUR - RESOURCES

Category Performance Indicator 2013/14 Actual

2014/15 Target

2015/16 Target

Resources - We will be financially sustainable and make efficient use of our resources to provide safe and welcoming environments, modern equipment, facilities, and technology, to underpin service transformation.

Outcome 4.1 - Achieve planned surpluses of £3.9m each year

Surplus Outturn surplus £3.9m £3.9m £3.9m

Outcome 4.2 - Best in class productivity and efficiency standards , delivered through quality assured CIPs

CIP Cumulative delivery of savings against plan £13.9m £16.1m £15.8m

Percentage 4.1% 4.6% 4.5%

Overall elective theatre utilisation 81% 83% 85%

Productivity and patient flow

Length of stay over 10 days 26.2% 23.5% 21.2%

Day case rates 82.7% 83.7% 84.7%

Day of surgery admission 89% 90% 91%

Average length of stay (days) 3.2 2.9 2.6

Continuity of services

Liquidity ratio (max 4) 3 3 3

Capital servicing capacity (max 4) 4 4 3

Overall rating (max 4) 4 4 4

Better Public payment policy

Performance against the prompt payment policy

95% 95% 95%

Elective surgery productivity programme

Number of theatre sessions per week 180 170 160

Outpatient improvement programme

‘Did not attend’ rate (%) 7.6 6.7 5.7

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Category Performance Indicator 2013/14 Actual

2014/15 Target

2015/16 Target

Improved productivity and quality for patients’ length of stay

Medical length of stay (elective and non-elective combined

3.4 3.1 2.9

Outcome 4.3 - Completion of our sites development plan phase 1 and achievement of expected patient and business benefits

Deliver clinical site development

Deliver planned spending on Clinical Site Development Plan

£8.9m £7.7m £4.5m

Outcome 4.4 - Fully utilised and robust, electronic patient care and management systems, supporting high quality, efficient care

Health Informatics Utilisation and efficiency of EPR. n/a

Successful procurement

Successful implementation and utilisation

E-discharge summary compliance 81% 85% 90%

Outcome 4.5 - Successful work with partners to achieve our sustainability goals adding value to the economic health of Cornwall and Isles of Scilly

Sustainable development

Establish the Sustainable Development Management Group. Implement work streams to deliver the plan key elements. Achieve 10% reduction in carbon emissions by 2016

Implement SDMG work streams

5% carbon reduction

10% carbon reduction

8 SERVICE PLANNING AND DEVELOPMENT

8.1.1 Divisional and specialty plans are developed so that they focus around the four strategic aims, as set out earlier in this plan:

Quality

People

Partnership

Resources

8.1.2 Within these plans, there are a number of exciting service developments which will improve services for patients in Cornwall and Isles of Scilly. For example. Sentinel node biopsy, Interventional Radiology, cardiac MRI, admissions avoidance/ new ways of providing services (gastroenterology hot clinic, heart failure clinic, orthopaedic virtual clinic).

8.1.3 The future provision of Vascular Surgery is a key service challenge in 2014/15 due to the specification of criteria for compliance with national guidance. Whilst our current service offers excellent outcomes, it does not meet the population criteria and also cannot be sustained by the current number of surgeons, Partnership options are being explored with Plymouth NHS Trust, work is on-going to influence local and specialist Commissioners and a business case is being prepared to review all options, with their

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respective implications. The loss of this service would have significant implications for the breadth and safety of services at RCHT.

8.1.4 The development of ‘24/7’ service provision is another key area where system-wide collaboration needs to be progressed in order to ensure that other parts of the delivery are aligned to compliment this ambition. This will include improved access to diagnostics, therapy and other services over the weekends. This area is a critical part of our response to the Future Hospitals’ report and also to driving improved morbidity and reduced mortality.

8.1.5 The following sections present some of the key issues identified from the Divisional and speciality plan which will be implemented during the coming periods.

8.2 KEY PRIORITIES FROM DIVISIONAL AND SPECIALTY PLANS

Medicine, Emergency Department and West Cornwall Hospital Division

Emergency care – make best use of the improved environment to improve patient flow, and deliver new models of care

Cardiology – implement the findings of the December 2013 external review, as part of the agreed strategy

Frailty – embed the Frailty Pathway ethos across the Trust and wider community

‘’Pioneer’’ – influence the developing pathways, skills, roles and services, linked closely to frailty pathway

Surgery, Theatres and Anaesthetics Division

All specialties to deliver elective plan and RTT recovery within available resources and achieve productivity goals

Ophthalmology - deliver streamlined access, reduce follow up pending lists, deliver expanded macular service for diabetic macular oedema and retinal vein occlusion, consider partnership options to increase capacity

Review pre-operative assessment service - seize opportunities for improved efficiency, such as the introduction of a web-based assessment element.

Trauma and Orthopaedics - focus on improving theatre productivity/utilisation and respond to commissioner challenges

General Surgery – work with consultants forming LLP to explore joint benefits

Progression of Elective Surgery option appraisal, interim utilisation of St Michaels Hospital

Women, Children and Sexual Health Division

Community Paediatrics - full service review to understand demand and capacity before alignment of service across the county

Maternity - develop midwifery-led birthing centre on RCH site to relieve pressure on existing delivery suite and deliver community birth target of 40%

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Gynaecology – embed learning from the 2013/14 review, improve RTT target to meet 90% on 18 week pathway, deliver a female surgical floor as part of the clinical site development plan and midwifery-led birthing centre, and respond to Community Elective Commissioner plans.

Sexual health - prepare the team and service for tender in April 15

Clinical Support Services and Cancer Division

Pathology - work with the Peninsula Steering Group to develop plans for pathology reconfiguration.

Oncology - implement recommendations from Oncology 2018 strategy and commission the second ‘TrueBeam’ linear accelerator, development of acute oncology service

Outpatients - transform service offer, through utilisation of technology, new pathways, skill mix and customer service focus

Various - Expedite patient discharge and patient flow – evaluate and deliver critical interventions e.g. pharmacy, therapy.

9 GOVERNANCE, RISK MANAGEMENT AND ASSURANCE

9.1.1 As a public body the Trust is accountable for how it uses its funds and assets in pursuit of its strategic aims. Ultimately the Board is responsible for the governance of the organisation. This includes putting in place proper plans for the planning, monitoring and delivery of its activities which are in accordance with the Trust’s policies, aims and objectives

9.1.2 The Board is constantly engaged in the process of risk management. This is achieved through the maintenance and review of the Board Assurance Framework (BAF) and the consideration of matters brought to its attention at subcommittees of the Board.

9.1.3 Additionally, significant internal control issues continue to be reported immediately via the Trust Management Committee, Audit Committee and Trust Board.

9.1.4 Once the business plan is approved, the Executive will consider the strategic and operational risks for the forthcoming 2 years and reflect them in the Board Assurance framework. It is expected that most of the themes will continue from those identified in 2013/14, but will build on the learning from key governance issues.

10 PERFORMANCE MANAGEMENT

10.1.1 Effective performance management remains critical to the Trust. The Trust Executive re-approved the Performance Management Strategy in September 2013, pending further consideration by the new Board once fully appointed. The Strategy provides a comprehensive framework for managing performance in the Trust.

10.1.2 The principles of performance management at RCHT remain as defined in the Performance Management Strategy. Good progress has been made on the implementation of the Strategy, with the key direction of travel over the next year being to progress the cultural shift to a greater degree of clinical and Specialty-level ownership

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and engagement in performance management. This is linked to both the 2018 Delivery Programme and the introduction of Service Line Management within the organisation.

10.1.3 The basic organisational performance management building blocks for 2014/15 are similar, but not identical to 2013/14, with changes including:

Strengthening of Specialty-level reporting arrangements (including incorporation of Specialty governance framework)

Finance and Performance Committee scrutiny of Divisional Performance Reviews, by exception

10.1.3 The key elements of our performance management framework are:

Committee Membership Reporting Documents

Level 1: RCHT Trust Board

Trust Board Full Board

- Integrated Performance Report (IPR)

- Board sub-Committee supporting information (e.g. re: compliance from Governance Committee or Board assurance from Audit Committee)

- Periodic deep dives, seminars or further investigation of issues

Finance & Performance Committee

Non-Executive Directors with CEO & lead Executives

- Presentation on key performance information, including detailed information and actions on any key business targets currently being failed

- Scrutiny and assurance regarding risks and adequacy of actions

- Escalation actions from Divisional Performance Reviews (by exception)

Trust Management Committee

Divisional Management Teams with CEO and lead Executives

- Scrutiny and assurance regarding risks and adequacy of actions

- Sign off of Integrated Performance Report

- Weekly scrutiny of ‘Hot Report’ of key performance issues suitable for weekly measurement and analysis

Level 2: Divisional Management

Divisional Performance Reviews

Lead Executives, Divisional Management Team/DFM/HR Business Partner

- Detailed Performance Assurance Framework for Division

- Divisional commentary

- Other issues by exception

Level 3: Specialty / Service Line

Specialty and department review process

Divisional Director, Divisional Management Team, Specialty Director, Service Lead and Matron

- Developing specialty-level Performance Assurance Framework (PAF) incorporating specialty governance framework

- Individual dashboards, locally held performance information, patient level information and costing system data

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- Risk assessment and mitigation

Level 4: Team / Individual

Ward and clinical area reviews

Specialty Director, HR and Finance Managers, Matron and Service Lead with Ward Sister or equivalent

- Ward trigger tools, budget review and other specific governance indicators as combined in Ward PAF

- Risk assessment and mitigation

Individual performance management arrangements

Individual and line manager

- Agreed objectives

- Appraisal and personal development review documentation

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APPENDIX 1 FINANCIAL PLAN 2014/15 (SUPPORTING STATEMENTS)

1. STATEMENT OF COMPREHENSIVE INCOME

1.1. The Statement of Comprehensive Income is attached as appendix 1.1 to this report. It identifies that the Trust’s projected surplus remains at £3.9m for both the 2014-15 and 2015-16 financial years. This is summarised in the following table with further explanations in the sections below:

Table 1 – Summary of Income and Expenditure

NHS Kernow contract 1.2. The Trust expects to earn £229.7m from its work commissioned by NHS Kernow. This is

the value the Trust expects to earn under a standard national contract and also reflects the impact of QIPP schemes proposed. As further QIPP schemes are developed, the Trust will revisit its Financial Plan to determine the impact of these schemes on its costs and income.

1.3. A standard national contract means that the income earned will be fully dependent upon the activity undertaken. Therefore, income could be higher or lower than this amount. The income earned will fully depend on the activity undertaken. Income may therefore be higher or lower than this amount. Higher income levels will bring associated costs. Lower income levels, beyond the value of the growth / activity reserve, will necessitate cost reduction.

2013-14 2014-15 £ change % change£000 £000 £000 %

INCOMENHS Kernow 223,930 229,735 5,805 2.6%Specialised Commissioning 47,282 48,482 1,200 2.5%Area Team 9,464 10,460 996 10.5%NCAs 4,767 4,424 (343) -7.2%Cornwall Council 3,040 3,054 14 0.5%Services provided 8,753 8,753 0 0.0%Other income 24,752 24,293 (459) -1.9%Interest receivable 98 98 0 0.0%Total income 322,087 329,300 7,213 2.2%

EXPENDITUREPay (202,559) (209,191) (6,633) 3.3%Non-pay (96,429) (97,367) (938) 1.0%Capital charges (19,199) (18,841) 358 -1.9%Total expenditure (318,187) (325,400) (7,213) 2.3%

Surplus 3,900 3,900 0 0.0%

Income and Expenditure

49 

 

2. EXPENDITURE

2.1. The key cost pressures, investments and changes in income that have been built into the 2014-15 budget are shown below. These changes drive the need to save £14m during 2014-15.

2.2 The level of reserves and contingency has been set to a level which makes the CIP target achievable and which provides for the highest risk areas of expenditure. A number of further contingency solutions exist should the CIP target not be achieved.

3 BALANCE SHEET AND CASH FLOW

3.1 Appendix 1.2 sets out the Balance Sheet for the Trust and includes the projected outturn for 2013-14 as well as the forecast balance sheets for 2014-15 and 2015-16. In addition and covering the same period, appendix 1.3 includes the cash flow forecast.

Historic debt

3.2 At 31 March 2014 the Trust will owe £19.6m in relation to its historic debt. Whilst officially

repayable in full in 2014-15, the Trust has received notification from the NHS TDA that a repayment of £1.6m can be made in 2014-15, and the financial plan has been set on that basis.

3.3 Following authorisation as an FT, the Trust fully expects to reschedule its debt over a

longer period of time to formalise the repayment of £1.6m and reduce its interest charge.

New debt 3.4 The proposed capital programme includes the recommendation to borrow £6m in relation

to capital investment in 2014-15. The costs of this borrowing are minimal for 2014-15 given the proposed timing of the drawdown of the debt. Any repayments made will be through capital resources and so have not impacted on the proposed surplus level.

Other balance sheet issues

3.5 There are no other balance sheet issues that materially impact on the financial plan for

2014-15.

Mar-14Cost pressure / investment £000Pay, non-pay inflation and CNST 8,447 Review of CIP schemes - 2013-14 2,416 Baseline pressures from 2013-14 3,609 New non-discretionary investments 2014-15 1,043

Centrally managed resource - operational risks 2,350

Centrally managed resources - specific contingency and other reserves

10,415

Centrally managed resources - discretionary investments

1,500

Increase in income from baseline level (7,398) Less: value of CMRs already buit into the budget

(8,381)

Level of CIP required 14,000

50 

 

4 CAPITAL PROGRAMME

4.1 The Capital Programme has been developed on the basis that:

All service maintenance and some service improvement schemes are funded, and steps taken to apply for the additional borrowing in 2014-15 of £6m.

Service improvement schemes which have a clear financial, or over-riding

operational benefit to the Trust, and with a reasonable pay-back period should be considered for approval on a case by case basis, and that the value and prioritisation of these schemes determines the level of additional borrowing.

4.2 The capital programme included as appendix 1.4 , summarises the capital programme

with an assumed borrowing level of £6m. This means that the capital programme for 2014/15 will be between £23.6m and £27.6m which provides an element of flexibility for schemes that are currently being assessed through the business case process. The value of mandatory schemes included within the programme is £21.7m for 2014-15 and £13.4m for 2015-16.

  51

APPENDIX 1.1 TO THE FINANCIAL PLAN 2014/15 – STATEMENT OF COMPREHENSIVE INCOME

Statement of Comprehensive Income 2013/14 2014/15 2015/16

Outturn Forecast Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Forecast

£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s

Operating Expenditure:

Gross Employee Benefits (204,037) (201,851) (17,619) (17,579) (17,768) (17,092) (17,132) (17,337) (16,156) (16,154) (16,343) (16,178) (16,350) (16,143) (198,477)

Other Operating Costs (103,026) (109,702) (8,158) (8,264) (8,242) (9,870) (8,601) (8,796) (10,436) (9,400) (9,003) (10,018) (8,993) (9,921) (116,355)

Total Operating Costs (307,063) (311,553) (25,777) (25,843) (26,010) (26,962) (25,733) (26,133) (26,592) (25,554) (25,346) (26,196) (25,343) (26,064) (314,832)

Operating Income:

Revenue from Patient Care Activities 297,181 301,503 24,658 24,790 25,187 26,264 24,905 25,505 26,081 24,434 24,405 25,245 24,280 25,749 304,955

Other Operating Revenue 32,203 32,013 2,684 2,686 2,633 2,686 2,684 2,635 2,684 2,685 2,633 2,686 2,685 2,632 31,925

Total Operating Revenue 329,384 333,516 27,342 27,476 27,820 28,950 27,589 28,140 28,765 27,119 27,038 27,931 26,965 28,381 336,880

EBITDA 22,321 21,963 1,565 1,633 1,810 1,988 1,856 2,007 2,173 1,565 1,692 1,735 1,622 2,317 22,048

Interest:

Investment Revenue 35 96 8 8 8 8 8 8 8 8 8 8 8 8 100Finance Costs (including interest on PFIs and Finance Leases) (1,550) (1,452) (121) (121) (121) (121) (121) (121) (121) (121) (121) (121) (121) (121) (1,333)Dividends Payable on Public Dividend Capital (PDC) (4,144) (4,200) (350) (350) (350) (350) (350) (350) (350) (350) (350) (350) (350) (350) (4,300)

Depreciation:

Depreciation (12,066) (11,950) (996) (996) (995) (996) (996) (995) (996) (996) (996) (996) (996) (996) (12,066)Donated/Government grant assets adjustment (depreciation of donated/grant funded assets) 45 412 51 51 1 51 51 1 51 51 1 51 51 1 (1,888)

Other: IFRIC12 384 443 37 36 37 36 37 36 37 37 38 37 38 37 451Donated/Government grant assets adjustment (donation income) 555 200 0 0 50 0 0 50 0 0 50 0 0 50 2,500

Amortisation:

Amortisation (1,680) (1,612) (134) (134) (135) (134) (134) (135) (134) (134) (135) (134) (134) (135) (1,612)

Adjuster Retained Surplus 3,900 3,900 60 127 305 482 351 501 668 60 187 230 118 811 3,900

2014/15 Per Month

  52

APPENDIX 1.2 TO THE FINANCIAL PLAN 2014/15 – BALANCE SHEET

Balance Sheet 2013/14 2015-16

Year-end Apr May June July Aug Sep Oct Nov Dec Jan Feb Mar Year-end

£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s

NON-CURRENT ASSETS:

Property, Plant and Equipment 158,613 160,189 160,158 160,350 160,912 162,561 163,479 164,053 164,622 165,652 166,788 168,434 170,230 172,902

Intangible Assets 4,526 4,392 4,257 4,123 3,988 3,854 3,719 3,585 3,450 3,316 3,182 3,048 2,914 1,302

Trade and Other Receivables 1,314 1,314 1,314 1,314 1,314 1,314 1,314 1,314 1,314 1,314 1,314 1,314 1,314 1,314

TOTAL Non Current Assets 164,453 165,895 165,729 165,787 166,214 167,729 168,512 168,952 169,386 170,282 171,284 172,796 174,458 175,518

CURRENT ASSETS:

Inventories 7,293 7,293 7,293 7,293 7,293 7,293 7,293 7,293 7,293 7,293 7,293 7,293 7,293 7,293

Trade and Other Receivables 14,137 12,687 12,937 13,187 13,437 13,687 13,937 13,187 13,437 13,687 13,937 14,187 12,437 12,437

Cash and Cash Equivalents 10,806 7,903 7,807 8,488 8,899 9,022 8,074 8,272 8,075 8,217 8,102 8,177 12,127 11,848

TOTAL Current Assets 32,236 27,883 28,037 28,968 29,629 30,002 29,304 28,752 28,805 29,197 29,332 29,657 31,857 31,578

TOTAL ASSETS 196,689 193,778 193,766 194,755 195,843 197,731 197,816 197,704 198,191 199,479 200,616 202,453 206,315 207,096

CURRENT LIABILITIES:

Trade and Other Payables (26,341) (23,433) (23,357) (22,604) (23,273) (24,873) (24,476) (23,758) (24,249) (24,413) (23,383) (23,165) (24,761) (25,594)

Provisions (383) (383) (383) (383) (383) (383) (383) (383) (383) (383) (383) (383) (388) (395)

Borrowings (28) (28) (28) (28) (28) (28) (28) (28) (28) (28) (28) (28) (28) (28)

Liabilities arising from LIFT (8) (8) (8) (8) (8) (8) (8) (8) (8) (8) (8) (8) (10) (12)

DH Working Capital Loans (1,916) (1,916) (1,916) (1,916) (1,916) (1,916) (1,916) (1,916) (1,916) (1,916) (1,916) (1,916) (1,916) (1,916)

DH Capital Investment Loans (286) (286) (286) (286) (286) (286) (786) (786) (786) (786) (986) (1,186) (1,386) (1,386)

Total Current Liabilities (28,962) (26,054) (25,978) (25,225) (25,894) (27,494) (27,597) (26,879) (27,370) (27,534) (26,704) (26,686) (28,489) (29,331)TOTAL ASSETS LESS CURRENT LIABILITIES 167,727 167,724 167,788 169,530 169,949 170,237 170,219 170,825 170,821 171,945 173,912 175,767 177,826 177,765

NON-CURRENT LIABILITIES:

Trade and Other Payables (4,108) (4,045) (3,982) (3,919) (3,856) (3,793) (3,730) (3,667) (3,604) (3,541) (3,478) (3,415) (3,352) (2,596)

Provisions (4,280) (4,280) (4,280) (4,280) (4,280) (4,280) (4,280) (4,280) (4,280) (4,280) (4,280) (4,280) (4,402) (4,511)

Liabilities arising from LIFT Scheme (1,558) (1,558) (1,558) (1,558) (1,558) (1,558) (1,558) (1,558) (1,558) (1,558) (1,558) (1,558) (1,548) (1,536)DH Working Capital Loan - Revenue Support (19,225) (19,225) (19,225) (19,225) (19,225) (19,225) (18,267) (18,267) (18,267) (18,267) (18,267) (18,267) (17,309) (15,393)

DH Capital Loan (2,785) (2,785) (2,785) (4,285) (4,285) (4,285) (4,142) (4,142) (4,142) (5,142) (6,942) (8,742) (10,899) (9,513)

Total Non-Current Liabilities (31,956) (31,893) (31,830) (33,267) (33,204) (33,141) (31,977) (31,914) (31,851) (32,788) (34,525) (36,262) (37,510) (33,549)ASSETS LESS LIABILITIES (Total Assets Employed) 135,771 135,831 135,958 136,263 136,745 137,096 138,242 138,911 138,970 139,157 139,387 139,505 140,316 144,216

TAXPAYERS EQUITY

Public Dividend Capital 165,852 165,852 165,852 165,852 165,852 165,852 166,497 166,497 166,497 166,497 166,497 166,497 166,497 166,497

Retained Earnings reserve (69,731) (69,671) (69,544) (69,239) (68,757) (68,406) (67,905) (67,236) (67,177) (66,990) (66,760) (66,642) (65,831) (61,931)

Revaluation Reserve 39,650 39,650 39,650 39,650 39,650 39,650 39,650 39,650 39,650 39,650 39,650 39,650 39,650 39,650

Total Taxpayers Equity 135,771 135,831 135,958 136,263 136,745 137,096 138,242 138,911 138,970 139,157 139,387 139,505 140,316 144,216

2014/15

  53

APPENDIX 1.3 TO THE FINANCIAL PLAN 2014/15 – STATEMENT OF CASH FLOWS

Statement of Cash Flows 2013/14 2014/15 2015/16

Outturn Forecast Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Forecast

£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s

Cash Flows from Operating Activities

Operating Surplus/(Deficit) (870) 8,601 435 503 730 858 726 927 1,043 435 611 605 492 1,236 10,870

Depreciation and Amortisation 13,746 13,562 1,130 1,130 1,130 1,130 1,130 1,130 1,130 1,130 1,131 1,130 1,130 1,131 13,678

Impairments and Reversals 10,000 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Donated Assets received but non-cash backed (555) (200) (100) (100) (2,500)

Interest Paid (1,511) (1,457) (33) (33) (33) (32) (33) (580) (33) (32) (32) (32) (32) (552) (1,333)

Dividend (Paid)/Refunded (4,139) (4,200) (2,100) (2,100) (4,300)

(Increase)/Decrease in Inventories (548) 0

(Increase)/Decrease in Trade and Other Receivables (2,033) 1,700 1,450 (250) (250) (250) (250) (250) 750 (250) (250) (250) (250) 1,750

Increase/(Decrease) in Trade and Other Payables 3,138 (975) (3,321) (490) (1,216) 255 1,187 1,786 (1,130) 76 (300) (1,443) (631) 4,252 1,637

Provisions Utilised (332) (374) (374) (381)Net Cash Inflow/(Outflow) from Operating Activities 16,896 16,657 (339) 860 361 1,961 2,760 913 1,760 1,359 1,060 10 709 5,243 17,671

CASH FLOWS FROM INVESTING ACTIVITIES

Interest Received 35 96 8 8 8 8 8 8 8 8 8 8 8 8 100

(Payments) for Property, Plant and Equipment (18,548) (23,367) (2,572) (964) (1,188) (1,558) (2,645) (1,913) (1,570) (1,564) (1,926) (2,133) (2,642) (2,692) (14,738)Net Cash Inflow/(Outflow) from Investing Activities (18,513) (23,271) (2,564) (956) (1,180) (1,550) (2,637) (1,905) (1,562) (1,556) (1,918) (2,125) (2,634) (2,684) (14,638)NET CASH INFLOW/(OUTFLOW) BEFORE FINANCING (1,617) (6,614) (2,903) (96) (819) 411 123 (992) 198 (197) (858) (2,115) (1,925) 2,559 3,033

CASH FLOWS FROM FINANCING ACTIVITIES

New Public Dividend Capital received in year 1,504 645 645 0

Loans received from DH - New Capital Investment 1,500 9,500 1,500 500 1,000 2,000 2,000 2,500Loans repaid to DH - Capital Investment Loans Repayment of Principal (286) (286) (143) (143) (1,386)Loans repaid to DH - Revenue Support Loans Repayment of Principal (1,916) (1,916) (958) (958) (1,916)Capital element of payments relating to PFI, LIFT Schemes and finance leases (7) (8) (8) (10)Net Cash Inflow/(Outflow) from Financing Activities 795 7,935 0 0 1,500 0 0 44 0 0 1,000 2,000 2,000 1,391 (3,312)NET INCREASE/(DECREASE) IN CASH AND CASH EQUIVALENTS (822) 1,321 (2,903) (96) 681 411 123 (948) 198 (197) 142 (115) 75 3,950 (279)Cash and Cash Equivalents (and Bank Overdraft) at Beginning of the Period 11,600 10,778 10,778 7,875 7,779 8,460 8,871 8,994 8,046 8,244 8,047 8,189 8,074 8,149 12,099Cash and Cash Equivalents (and Bank Overdraft) at the end of the period 10,778 12,099 7,875 7,779 8,460 8,871 8,994 8,046 8,244 8,047 8,189 8,074 8,149 12,099 11,820

2014/15 Per Month

  54

APPENDIX 1.4 TO THE FINANCIAL PLAN 2014/15 – CAPITAL PROGRAMME AND FINANCING (2014/15 AND 2015/16 ARE APPROVED, SUBSEQUENT YEARS ARE INDICATIVE)

Capital Programme and Financing2014/15

Plan2015/16

Plan2016/17

Plan2017/18

Plan2018/19

Plan TOTAL

£000s £000s £000s £000s £000s £000s

SUMMARY OF PLANNED CAPITAL PROGRAMME

Estates 3,452 2,350 2,100 2,100 2,382 12,384

Health Informatics 5,911 4,822 2,856 2,788 3,018 19,395

Medical Capital Equipment 6,507 2,661 6,288 5,559 4,899 25,914

Clinical Site Development Plan 7,697 4,905 8,620 2,855 13,262 37,339

Service Development 0 0 467 451 846 1,764

GROSS PLANNED CAPITAL EXPENDITURE 23,567 14,738 20,331 13,753 24,407 96,796

PLANNED FINANCING OF CAPITAL EXPENDITURE

Internal Sources:

Planned Depreciation - Non IFRIC 12 Related 13,508 13,624 13,917 14,699 14,753 70,501

Planned Depreciation - IFRIC 12 Related 54 54 54 54 54 270Less Planned Depreciation - IFRIC 12 Related Depreciation that forms Part of the Unitary Charge (54) (54) (54) (54) (54) (270)Net Book Value of Non Current Assets Disposed Of to NHS and non-NHS Orgs 0 0 0 0 3,000 3,000

Grants and Donations 200 2,500 200 200 200 3,300

Internally Generated Capital Cash 13,708 16,124 14,117 14,899 17,953 76,801

External Sources:New Public Dividend Capital - Central DH Programme (Policy) Budget Allocations - Agreed/Anticipated 645 0 0 0 0 645New Public Dividend Capital - Exceptions To The Capital Regime (Exceptional PDC) 0 0 0 0 0 0

Loan received from DH - Capital Investment 9,500 0 7,600 1,000 8,700 26,800

External Capital Cash Requirement 10,145 0 7,600 1,000 8,700 27,445

Total Capital Cash Financing 23,853 16,124 21,717 15,899 26,653 104,246Total Capital Cash Available to repay Capital Loans 286 1,386 1,386 2,146 2,246 7,450