CONTENTS · CONTENTS 2 AMS/KT/601v8 08.10.13 8. Enabling Strategies 57 8.1 Estate Strategy – The Challenge 58 8.2 Informatics Strategy 65 8.3 Workforce Strategy 67 8.4 “Back Office”

CONTENTS

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BOLTON NHS FOUNDATION TRUST STRATEGIC DIRECTION 2013/14 -2018/9

Page

1. Executive Summary 5 1.1 Context and Challenges 6 1.2 Our Objectives 7 1.3 Our Strategic Direction 7 1.4 Achieving Financial Health 8 1.5 Our Strategy at a Glance 9 2. Trust Profile 11 2.1 The Trust 12 2.2 Catchment 13 2.3 The Bolton Health Economy 14 2.4 Performance and Trends 2011/12 – 2013/14 15 3. Our Vision and Values 17 3.1 What do we aim to achieve? 18 3.2 The Service we aim to provide in future 19 3.3 Our Values 20 4. Strategic Context 21 4.1 What factors will influence our future? 22 4.2 “Healthier Together” – Greater Manchester-wide Review of Healthcare –

A major Influence on Our Future 25

4.3 Local Commissioning Intentions – Bolton Clinical Commissioning Group’s Strategy

26

5. Market Assessment 29 5.1 Strengths, Weaknesses, Opportunities and Threats 30 5.2 Competition – Hospital Services 31 5.3 External Comparative Review 31 5.4 Independent Sector 32 5.5 Market Share 32 6. Clinical Services Strategy 33 6.1 Our Core Business 34 6.2 What Does this Mean for the Trust’s Portfolio of Services? 36 6.3 What are the service priorities which are essential to achieving our strategy

for clinical services? 38

7. A Strategy for High Quality 51 7.1 Our aims for the Quality of Care in Our Organisation 52 7.2 Key Ambitions 52 7.3 Organisational Culture/Workforce Capability 53 7.4 Delivering the Strategy 53 7.5 Our Goals 54 7.6 Essential Enabling Workstreams 54 7.7 Measurement 55 7.8 Governance 56

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8. Enabling Strategies

57

8.1 Estate Strategy – The Challenge 58 8.2 Informatics Strategy 65 8.3 Workforce Strategy 67 8.4 “Back Office” 69 9. Financial Analysis and Plans 71 9.1 Summary of Financial Plans 72 9.2 Historic Position 73 9.3 Income and Expenditure Plan 75 9.4 Income Analysis 79 9.5 Income and Cost Improvements 82 9.6 Capital Programme 88 9.7 Statement of Financial Position 90 9.8 Continuity of Services Rating 92 9.9 Downside Risk Analysis 93 10. Organisation Risk 95 10.1 Corporate Risk Profile 96 10.2 Downside Projections 98 11. Organisational Delivery 99 11.1 Governance 100 11.2 Organisational Development and Leadership 101 11.3 Partnerships 103 11.4 Managing Performance 103 11.5 Programme and Project Management 104 105 Appendices A Bolton Integrated Care Plan 106 B Quality Strategy 106 C Estates Strategy 106 D Informatics Strategy 106 E Workforce Strategy 106 F Internal Audit Plan 2013/14 106 G Performance Framework Dashboard 106 H Financial Appendices

H.1 Planned Statement of Comprehensive Income H.2 Planned Statement of Financial Position H.3 Planned Statement of Cash Flows H.4 Planned Continuity of Services Rating (Loan Finance) H.5 Planned Continuity of Services Rating (PDC Finance) H.6 Planned Statement of Comprehensive Income - Bridge H.7 Planned Income - Bridge H.8 Planned Statement of Comprehensive Income - Monthly Phasing H.9 Planned Income and Cost Improvements H.10 Planned Capital Spend H.11 Estates Strategy Summary H.12 IT Strategy Summary H.13a Cash reconciliation - Loan finance

107 107 107 107 107 107 107 107 107 107 107 107 107 107

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H.13b Cash reconciliation - PDC finance H.14 Loans reconciliation H.15 Summary Activity Forecast H.16 Detailed Activity Forecast H.17 Bed Base Impact H.18 Workforce Plan - Summary H.19 Workforce Plan - Bridge H.20 Downside Risk - Income and Expenditure H.21 Downside Risk - Cash H.22 Healthier Together Estimates H.23 Income Upsides H.24 LongTerm Efficiency Plan H.25 Community Services Long Term Financial Plan H.26 Letter from Bolton CCG

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

Glossary of Abbreviations 108

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EXECUTIVE SUMMARY

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EXECUTIVE SUMMARY

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1. EXECUTIVE SUMMARY

This strategy sets out a realistic and achievable future for the Trust over the next three to five

years. It maps a clear course to achieving financial stability, taking account of the anticipated impact of demographic change and plans for a significant re-balancing between hospital and community-based care, and a constrained financial settlement. Most importantly, it consolidates and builds on the Trust’s commitment to high quality care, secured through a focus on specific areas of service improvement, and supported by organisation-wide developments in the estate, informatics and the workforce. The future range of services described in this plan is broadly similar to today’s Trust portfolio, although anticipating significant change, in particular, in the development of better integrated community-based systems of care, capable of supporting many more people in the community, and with reduced dependency on hospital and acute care. Building on a recent external comparative analysis, individual services will continue to focus on achieving and sustaining highest clinical standards, while also meeting target efficiency gains. We believe there are opportunities to redesign the way we work to achieve both of these goals.

1.1 Context and Challenges

Bolton NHS Foundation Trust provides hospital and community health services to the Bolton population and to a significant catchment area beyond Bolton. In common with other NHS organisations, Bolton NHS Foundation Trust’s outlook for the next three to five years is dominated by the twin challenges of improving quality and responding to changing demands on the service, while managing within a static or reducing budget. The Trust looks towards the next three years from a position where, in the previous year, it was found in breach of conditions two, five and six of the Foundation Trust Terms of Authorisation. This breach related to a failure to achieve access targets followed by identification of governance failings and an unplanned and unexpected financial deficit. The Trust has already seen steady improvement over the last twelve months:

The Trust is on course to reduce its financial deficit from £14.4m in March 2013 to £7.8m in March 2014. The intention, set out in this plan, is to achieve financial (run-rate) balance by 2013/14 and £1.6m surplus by the end of 2014/15.

Access time targets have been achieved and maintained, including performance on the four-hour Accident and Emergency access target which has been better than most other peers in Greater Manchester and beyond.

Despite being above target for cases of C.Difficile in the current year, the incidence is markedly lower than last year as a result of systematic implementation of the Trust-wide improvement plan.

Hospital mortality rates have also shown a continued steady reduction.

improvements in medical patient pathways in particular, have resulted in lengths of stay which compare well with the best in the country.

There have also been pleasing improvements in objective measures of patient

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experience.

As with other areas in the country, Greater Manchester, and the boroughs within it, are anticipating system-wide changes which will be needed to sustain affordable and effective health and care services over the coming years. There are two significant factors that are relevant to Bolton NHS FT’s plans:

Firstly, plans to re-shape local health and care services, to provide much more prevention, early intervention and care in the community, keeping people out of hospital wherever that is possible.

Secondly, the Manchester-wide review (‘Healthier Together’) which is developing new models of hospital care, for consultation later this year, aimed at securing financially and clinically sustainable services across the area.

This Statement of Strategic Direction sets out to describe a viable and strong future for

this organisation, and how the Trust will respond these strategic challenges.

1.2 Our Objectives

This strategy builds on this year’s positive foundations, to achieve the Trust’s over-riding objectives for the next five years:

Improved care

- improved outcomes for patients; - improved patient experience; - better integrated care; - safer care across patient pathways in hospital and community.

To be financially strong

To be well governed

To be a great place to work

To be fit for the future

1.3 Our Strategic Direction

Central to our strategy is our view of the range of services we will be providing over the

next three to five years. The Trust is clear that it aims to:

Build on the advantages of being an integrated provider of local hospital and community-based health services to deliver, with our partners, best care for patients throughout their healthcare journeys.

Focus on prevention, early intervention and keeping people healthy , as well as to provide excellent care for people who need treatment.

Remain a major provider of A&E , and medical and surgical emergency access services on the RBH site.

Continue to develop as a centre of excellence for Women’s and Children’s Services.

Retain and develop a range of planned diagnostic and treatment services (which are clinically and financially viable, and support the wider provision of services in the Trust).

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The Trust will act in partnership with other organisations to provide and sustain high quality care, when this is the most appropriate solution.

The strategy outlined in the following pages describes our intention to align the efforts of our “front-line” services and our supporting functions to deliver the Trust’s objectives and its plan for the development of clinical services.

The diagram overleaf provides a view of the main elements of our strategy.

1.4 Achieving and Maintaining Financial Health

The five-year financial plan that supports the delivery of the Trust’s strategy

demonstrates how the Trust will: Return to surplus in 2014/15 Achieve a continuity of service rating of two in 2014/15, rising to three in 2016/17 Achieve sufficient surplus to finance the Estates Strategy Achieve sufficient surplus to finance the IT Strategy Effectively manage downside risk

To do this the Trust will deliver: Income and cost improvements of £73.1m over five years.

Support is required to facilitate the plan: Temporary public dividend capital issued by the end of 2013/14 to be made

permanent Agreement of non-commercial loans or public divided capital to facilitate the

Estates and IT strategy It should be noted that agreement of public dividend capital to facilitate the Estates

and IT strategy would improve the Trust’s continuity of services rating allowing a three to be delivered in 2015/16 and a four in 2016/17 and beyond.

The income assumptions in the plan are prudent and have the support of the Bolton Clinical Commissioning Group.

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TRUST PROFILE

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In this section: Headline facts and figures about the Trust and its catchment

population, particularly the health status of the Bolton population

An outline of trends in performance over the last three years

Key points: This is an integrated, hospital/community service

provider for the Bolton population. The Royal Bolton Hospital is a major provider of

emergency services in Greater Manchester. 25% of all non-elective work and 30% of obstetric work

originates from outside Bolton. A&E attendances have risen by 6.5% over the three

years 2010/11-2012/15. The Bolton population generally demonstrates poor

health indicators, and significant inequalities across the borough. This is an influential factor in shaping Trust services over the next five years.

Performance on a range of key indicators has shown marked improvement over the last three years, particularly on access times and reduction of healthcare acquired infections. There remain some significant performance challenges, including the continuing reduction of cases of C. Difficile, staff sickness absence and achievement of financial surplus (planned by the end of 2014/15).

These issues are addressed later in the strategy, particularly in relation to our service plans (Section 6) and Quality Strategy (Section 7).

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2. TRUST PROFILE

2.1 The Trust

Bolton NHS Foundation Trust (BFT) comprises a broad range of hospital and

community-based services.

It has annual turnover of £272million and employs 5,200 wte staff.

The majority of secondary diagnostic, treatment and care services provided from Royal Bolton Hospital (RBH) are DGH-level emergency and elective specialisms, but RBH also represents a major hub within Greater Manchester for women’s and children’s services. In 2011, following implementation of the Greater Manchester-wide Women’s and Children’s Services reconfiguration Bolton became one of only three neonatal level 3 centres and one of eight 24-hour paediatric and consultant-led obstetric providers. The Trust now provides care for approximately 6,4 00 births p.a.

84.3% of inpatient admissions are non-elective. Royal Bolton Hospital is the

second busiest ambulance-receiving site in Greater Manchester.

Hospital services provide approximately 80% of acute care for the population of Bolton. Approximately 25% of the Trust’s activity is provided for non-Bolton residents – predominantly for patients from Wigan, Salford and Bury.

Hospital and community services in Bolton merged in July 2011 creating an

integrated local healthcare provider, increasing the size of the former Bolton Hospitals NHS Foundation Trust by some 1,500 staff and approximately £65m income.

Community services comprise a broad range of community-based preventive,

treatment and care provision, almost exclusively for the population of Bolton (with some small exceptions).

Virtually all community services and a significant element of hospital services

serve a common catchment with Bolton’s council and primary care services. The Trust is a full member of the Bolton Health and Wellbeing Board and Bolton’s Vision Partnership.

In 2012, the Trust was found in breach of its terms of FT authorisation due to

performance failures on two access targets: the A&E four-hour target and the 18-week referral to treatment target. The Trust was subsequently found also to be in breach of its financial and governance obligations and formally placed in “turnaround” by the regulator, Monitor.

The subsequent programme, supporting financial turnaround, aims to restore financial balance by returning to surplus in 2014/15.

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2.2 Catchment

Bolton NHS Foundation Trust is a major provider of hospital and community health services in the

North West Sector of Greater Manchester, delivering services from the Royal Bolton Hospital (RBH) site in Farnworth, in the South West of Bolton, close to the boundaries of Salford, Wigan and Bury; and also providing a wide range of community services from locations within Bolton. The RBH site is close to the junction of the M60 and M61 motorways and, for non-elective services in particular, is estimated to have a catchment population of 310-320,000, compared with a resident Bolton population of 270,000.

In 2012/13 the majority of hospital activity was commissioned by NHS Bolton for its resident population but a significant proportion of work came from neighbouring areas:

Bolton Hospital NHS Foundation Trust FFCEs split by CCG and Patient Type, Excluding well babies - Period: April 2012 – March 2013

Elec IP and DC Non-Elec Obstetrics Total

Number % Number % Number %

NHS Bolton CCG 25,246 77.16% 26,138 75.12% 9,327 61.20% 60,711

NHS Bury CCG 1,118 3.42% 963 2.77% 1,887 12.38% 3,968

NHS Salford CCG 2,820 8.62% 2,224 6.39% 2,283 14.98% 7,327 NHS Wigan Borough CCG 2,767 8.46% 3,879 11.15% 1,430 9.38% 8,076

Other 770 2.35% 1,592 4.58% 314 2.06% 2,676

Total 32,721 100.00% 34,796 100.00% 15,241 100.00% 82,758

PCT

A&E Attendances

2010/11 2011/12 2012/13 % Change

NHS Bolton CCG 82637 83888 86813 4.8%

NHS Wigan Borough CCG 11653 11247 12104 3.7%

NHS Salford CCG 8421 9518 9954 15.4%

NHS Bury CCG 1951 2230 3099 37.0%

Other 3749 3850 3950 5.1%

Total 108411 110733 115920 6.5%

Arrived by Ambulance Att's 28708 28874 30028 4.4%

% Arrived by ambulance 26.5% 26.1% 25.9% Data from the North West Ambulance Service shows that the RBH site receives approximately 20% more ambulance arrivals than other DGH sites in Manchester. 26% of all non-elective attendances arrive by ambulance.

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2.3 The Bolton Health Economy

Some facts and figures about the Bolton population:

21% of the adult population smoke 58% do not achieve the recommended levels of physical activity each week

with 17% undertaking no physical activity at all 55% do not eat a healthy diet

54% are overweight or obese

24% drink more than the recommended units of alcohol

14% experience poor mental wellbeing

Over 21, 000 people aged 40 years and over have been identified at high risk

of cardio-vascular disease. Across GP practices in Bolton 10,500 people are identified has having coronary heart disease, 13,000 diagnosed with chronic kidney disease, 16,440 with Diabetes, 2,300 with serious mental illness and 22,772 with depression.

Approximately 1350 new cases of cancer are diagnosed each year (2007-09

average). The most commonly diagnosed cancers are lung, breast, bowel, and prostate. Skin cancer diagnosis is also rising. Almost 30% of all new cancers diagnosed during 2007-09 were skin cancer.

Over a third of the adult population in Bolton are living with long term

conditions, many of whom have multiple long term conditions. People with physical long term conditions are more likely to experience mental health problems than the general population leading to even poorer health outcomes and reduced quality of life. People with long term conditions are the most frequent users of healthcare services and are also likely to have greater need of social care support, especially those with both physical and mental health problems.

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2.4 Performance and Trends – 2011/12 – 2013/14

2011/12 2012/13 2013/14

QUALITY

1. SHMI (standardised hospital mortality) 1.0612 1.0147 -

2. Control of Infection – MRSA Incidence 3 5 0

3. VTE Assessment – coverage 65.8% 96.8% 96.5%

4. Stroke Sentinel Audit Score 42.8 68.8 77.6

5. Cancer Patient Experience Survey 89.2% 94% Not available

6. Single Sex Accommodation breaches 104 1 1

FINANCE

7. Financial balance (£1.9m) (£14.4m) (£7.8m) projected

7a. Reference costs 92 104

ACCESS

8. 18 Weeks referral to treatment

8a Admitted 87.5% 86.7% 95.2%

8b Non admitted 97.7% 98.4% 96.0%

8c Incomplete 94.2% 95.6% 94.7%

9. A&E 4-hour access 95.1% 96.9% 96.9%

10. Cancer Access times (2 week waits) 98.3% 96.5% 96.4%

EFFICIENCY

11. Elective Length of Stay (average) days 3.0 2.9 3.1

12. Non Elective Length of Stay (average) 4.1 3.9 3.8

13. Daycase Rate 79.1% 79.9% 80.4%

14. New: Follow Up Ratio (outpatients) 1:1 97 1:1 99 1:1 67

15. Theatre Utilisation 83.9% 81.7% 83.8%

16. Number of Elective/Non Elective Inpatients (Excluding Obstetrics)

64746 67633 69228

WORKFORCE

17. Sickness Absence 4.69% 4.67%

18. Mandatory Training Coverage 75.0% 80.7%

19. Staff Appraisal Coverage 80.5% 81.2%

1. SHMI - data for 2011/2 is for the period April 11 to March 12, the 12/13 figure is the latest available data which is

January to December 12. 2. Number of Post 48 hour MRSA cases in the financial year. 13/14 is a forecast outturn based on 5 months (5/12ths)

3. VTE assessment, cumulative percentage for the financial years. 13/14 based on April to August 13.

4. Stroke Sentinel Audit - Average of 12 indicators score. 11/12 figure is the position for April to June 11, 12/13 figure is the position for April to June 12 and the 13/14 figure is the position at October to December 12 (latest available)

5. The score given is the percentage of patients that rated the care as excellent or very good, for all tumour sites.

6. Single Sex Accommodation breaches, the number of reportable breaches. There has been one in the period April to August 2013

7a. Reference costs. 12/13 figure is the indicative, not finalised figure (100 = England Average) 2011/12 : hospital only = 89 2012/13 : hospital only = 101

8. 18 week access targets, is the percentage seen within 18 weeks for the 3 pathways. Positions as at March 12, March

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13 and August 13 9. A&E performance against the 4 hour target. Financial years 11/12 includes walk in centre performance, 12/13

includes walk in centre for April to July 2012 10. % of patients seen within 2 weeks of referral for suspected cancer. Cumulative for the financial years, 13/14 is April

to July 13 11. Average length of stay in days for elective patients. The 2013/14 figure refers to April to August.

12. Average length of stay in days for non-elective patients. The 2013/14 figure refers to April to August.

13. Daycase rate = daycases/elective Inpatients + daycases.

14. 2013/14 : current performance

15. Theatre utilisation for core theatres

16. Combined number of elective and non-elective inpatients but not including Obstetrics. The 2013/14 figure is a forecast outturn based on April to August (5/12ths)

OUR VISION AND VALUES

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In this section: A summary of our where we see our organisation in five

years’ time The Trust’s high-level aims A summary of the services we plan to provide in future

Key points: The tests we will apply to our plans are based on our

aims: - improved care; - to be financially strong; - to be well-governed; - to be a great place to work; - to be fit for the future.

The Trust’s future range of services: - integrated care for the Bolton community; - services which keep people healthy and which intervene early; - major A&E and medical and surgical emergency receiving services at Royal Bolton Hospital; - a centre of excellence for women’s and children’s service; - a range of planned diagnostic and treatment services. (Working in partnership with other organisations when this is most appropriate.) The strategic challenges and planning priorities associated with each of these are set out in Section 6.


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3. OUR VISION AND VALUES

3.1 What do we aim to achieve?

Our Vision

To be an excellent integrated care provider within the district of Bolton and beyond, delivering patient-centred, efficient & safe services.

Our vision and values provide the foundation for the Trust’s decision-making; for communicating its priorities and plans to staff and to the wider group of people who have a stake in the future of this organisation and the services that it provides. At the highest level, we firmly believe that this is what we aim to achieve:

IMPROVED CARE - Improved clinical outcomes for patients - Improved patient experience - Better integrated care - Safer care across patient pathways, in hospital and community

TO BE FINANCIALLY STRONG

TO BE WELL GOVERNED

TO BE A GREAT PLACE TO WORK

TO BE FIT FOR THE FUTURE

This means:

The quality and safety of care - Not accepting anything less than highest quality and professionalism in everything we do

The experience of patients - Having a strong reputation with our

community, based on patients’ and visitors’ own experience of a caring, competent and responsive organisation

Our role in serving the local population - Recognising our significant role in

responding to the needs of the Bolton population, in partnership with primary care and social care, as well as our wider role in Greater Manchester

The way we use resources - Continually seeking ways of doing things

that drive out waste, reduce cost and improve quality

- Being a reliable steward of public monies

The way we care for and develop our workforce

- Being an organisation where people want to come and work


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3.2 The Services We Aim to Provide in Future

Financial turnaround is an essential pre-requisite for the stability and strength of

the Trust in future; but we recognise that our success will, essentially, be about continuing improvement in quality of care and in the experience of patients, and in the development and positioning of our services to do the job that our population and our patients need us to do.

The Building Blocks of the Trust’s Clinical Services Strategy:

These are the foundations of our service strategy:

Bolton NHS FT will build on the advantages of being an integrated provider of local hospital and community-based health services to deliver, with our partners, the very best care for Bolton patients throughout their healthcare journeys. We will focus on ensuring the best care for frail elderly people and people with long term conditions, outside hospital, through design and delivery of effective pathways of care.

Prevention, early intervention and keeping people healthy is central to why

we are here, as well as to provide excellent care for people who need treatment

Royal Bolton Hospital will remain a major provider of A&E and medical and

surgical emergency access services

The Trust will continue to develop as a centre of excellence for women’s and children’s services, remaining one of Greater Manchester’s hubs for those services

The Trust will retain and develop a range of planned diagnostic and

treatment services which

- Can sustain high standards, have critical mass and are clinically viable - Meet the needs and preferences of patients - Make a positive financial contribution and/or - Are essential to sustaining the wider service provision in the Trust

(The Trust expects to act in partnership with other organisations to provide and sustain high quality care when this is the most appropriate solution)


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3.3 Our Values

The Trust’s Values have been shaped by staff themselves:

Putting patients and staff at the heart of everything we do

To be respected To be valued To be proud

STRATEGIC CONTEXT

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In this section: An overview of the external ‘drivers’ which the Trust has

taken account of in its thinking about the future (political, economic, social, technological)

An outline of the emerging models of care from the Greater Manchester-wide service review ‘Healthier Together’.

An outline of the plans and priorities of local commissioners (the Bolton CCG)

Key points: The Trust is operating in an environment of accelerating

change. National and local policy development is increasingly geared

to dealing with demand driven by demographic and social trends, through new models of more targeted care, increasingly enabled by digital technology.

The population trends in Bolton suggest increasing pressure in both the younger age groups (as a result of the rising birth-rate over recent years) and the older age groups, particularly in over-65s.

The final models to result from ‘Healthier Together’ are not yet clear. Current proposals suggest greater centralisation of acute hospital care, in fewer centres. They also envisage a greater shift to community-based services and primary care, in localities. This is very much the model envisaged by Bolton CCG.

The Trust has reflected the anticipated service shift locally in the plans to develop better integrated care outlined in this strategy. In terms of hospital services, the assumptions underlying our activity and financial projections take account of this shift (more than 4000 fewer emergency admissions envisaged in three years’ time). They do not assume in the base case, any significant impact as a result of other aspects of ‘Healthier Together’ (hospital service reconfiguration).

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4. Strategic Context

4.1 What Factors will Influence Our Future?

The environment in which the Trust is operating is changing rapidly, with significant

developments in policy, the economy, social trends and technological progress which will influence the Trust’s plans:

POLITICAL

NHS reforms

The NHS reforms launched in 2010 have led to significant reorganisation and change across the service, most notably in the commissioning arrangements which have placed local commissioning with GP-led Clinical Commissioning Groups, but also establishing a wider arrangement at conurbation and regional level under the auspices of the new National Commissioning Board which sets the framework for planning and priorities across the system. Monitor, as regulator of NHS providers, now has a role in overall market management. Public health services and commissioning have, in part, moved into local authorities.

Increased patient choice/ competition

The 2010 reforms have brought about more extensive competition through the “Any Qualified Provider” process, requiring commissioners openly to tender for a wider range of services, and providing for NHS and non-NHS providers to bid to be recognised providers of services or part-services.

Increased focus on standards/compliance

With related penalties and incentives NHS standard contracts now require an increasing range of compliance measures. Regulation and scrutiny of the NHS have intensified. Monitor, the CQC, the Chief Inspector of Hospitals, and other external bodies, and the FT licencing régime are key cornerstones of a more public and rigorous system of inspection and performance management. The Francis Report, and the subsequent Care Bill, have set out further changes to strengthen the assessment and improvement of NHS Services.

ECONOMIC

Local community – deprivation

Indicators of deprivation show some areas of Bolton amongst the worst in the country.

These are reflected in corresponding poor health status.

The impact of the recession can be seen in increasing rates of unemployment. Bolton Council’s Health and Wellbeing Strategy, which sets out the key health priorities for the Borough over the next three years says being out of work leads to poor health and has a “significant negative psychological impact”, and reveals 49,600 people in Bolton – 29.5% of the Borough’s working age population – are “economically inactive”.

The overall figure is higher than both the North West and national averages.

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NHS funding pressures

In response to the national economic position and pressure on public finances, the NHS is

required to save £20billion by 2014/15 and further significant savings are expected to be needed for at least the following four to five years. Nationally, the Quality, Innovation, Productivity and Prevention (QIPP) Programme is expected to underpin delivery of cost reduction while improving the quality of care and outcomes, by reforming the way the whole service works to prevent ill health and deliver care.

Local Authority funding pressures and changes in social care

National policy on the organisation of adult social care services has, over recent years, seen an increasing shift away from the Social Services Department as a provider of services to being a commissioner of services. This is further emphasised in recent Government policy, in particular the development of “personalisation”, with allocated funds held and spent by individuals according to their own preferences of where, how and by whom their care needs are met. In common with other public services, social care is facing significantly reduced funding over the next two years (in Bolton, a minimum reduction of [40%] over this period), underlining the need for maximum value from integrated working in health and social care in order to maintain and care for the population, with least duplication.

Bolton Council have set out a model for the client’s “journey”, describing a system of eligibility assessment, and a re-shaped model of care – services or funding to be provided on the basis of “eligible need”

The model focuses strongly on improvement of information and advice available to individuals, and on the wide coverage (aiming for 80%) of a short term multidisciplinary assessment of referrals. This is designed to establish care needs and achieve significant reablement (eight weeks maximum), avoiding further deterioration and more complex demand on services, where this is possible.

It is intended that many more people will access this service than do currently, instead of being referred directly for a service.

For those with established longer term needs, it is expected that many more people will begin to take control of their package of care or “self-directed support”, enabled through “personalised” budgets, able to be used by a client to procure their preferred type of care.

In response to the reduced funding available, people with needs classed as “moderate” do not now qualify for Council support, restricting this to those with “critical” or “substantial” needs.

SOCIAL

Ageing population

The number of older people in Bolton over 65 is projected to grow from 46,000 in 2013 to

51,900 by 2020. Bolton’s age structure is also predicted to change significantly in the next twenty-five years. The proportion of the population aged 65 and above is set to increase from 15.4% in 2008 to 22.0% in 2033. Bolton’s working age population (age 20-64) is expected to decrease in number by 2.9% by 2033, the proportion of working age people in the population as a whole will reduce from 58.4% in 2008 to 52.9% in 2033.

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Public expectation

National and local trends reflect growing public expectation both of the capability and

availability of health services. Access to more intelligence and comparative information about health and health services has reinforced this trend, and underpinned an increasing willingness to exercise choice.

Population health indicators

Life expectancy is commonly used as an indicator to gauge and compare the health and well-being of a population. The most commonly used indicator is life expectancy at birth i.e. the number of years that a baby boy or girl can expect to live to. Life expectancy in Bolton remains lower than the national average and the gap continues to widen. Large internal life expectancy inequalities exist within Bolton, particularly for women. The steep social gradient within Bolton plays a significant role within this inequality. The all age all cause mortality rates continue to fall within Bolton but not as fast as the England rate. The major causes of death in Bolton, circulatory disease (CVD), respiratory disease and cancers (mainly lung) contribute approximately half of the gap in life expectancy. Alcohol- related digestive diseases are another significant contributor. Smoking in Bolton remains high, especially in the more deprived areas and this is a significant contributor to health inequalities in the borough. The prevalence of obesity continues to increase both nationally and locally. Inequalities related to deprivation persist within Bolton.

TECHNOLOGICAL

Potential of IT

Acceleration of the capacity and functionality of new technology, its familiarity and its

increasingly dispersed access, based on wifi and broadband capability, has the potential to transform models of care in the health service. The NHS Informatics Strategy envisages technology as the platform for more locally-based services, greater patient empowerment through access to records and other information, and the development of single records across diverse providers, supporting more integrated care.

Development and spread of new diagnostic and treatment capabilities and technologies

The National QIPP Framework has highlighted the benefit of innovation and rapid adoption as a significant element in responding to the challenge of improving quality and reducing cost (“Innovation, Health and Wealth”). Academic Health Science Networks have been established across the country to accelerate the benefits of area-wide redesign and adoption of best practice, harnessing the collaboration of providers, commissioners, academics and industry.

STRATEGIC CONTEXT

25 AMS/KT/601v8 08.10.13

4.2 “Healthier Together” – GM-wide Review of Healthcare – A Major Influence on Our

Future

In 2012 NHS Greater Manchester launched a major review of health services across the conurbation. Models for future provision, based on work developed in clinical reference groups over the last eighteen months, have been published and it is planned to undertake to a more formal consultation process, which will put forward proposals for change in the organisation and location of services, particularly the distribution of acute hospital services across Manchester. Consultation is anticipated by quarter four 2013/14.

The high-level conclusions emerging from Healthier Together describe a need for significant change in order to meet the challenge of improving care and outcomes, while also addressing increasing demand and continuing reductions in public spending.

Emerging Headlines From Healthier Together About Possible Future Models of Care:

Primary Care Better access – 365/365 Bigger GP groupings Closer working with secondary care clinicians Less variation

Frail Elderly/People with Long Term

Conditions More geriatricians outside hospital Acute and community response 24/7 Patients able to make their own choices Integrated acute access/rehabilitation/supported

discharge and pathways

Emergency Surgery (and Complex Elective Surgery)

All high risk operations consultant-delivered All patients on integrated pathways Patient risk determining the seniority and urgency

of response Centralised high risk/intermediate surgery at

designated sites Lower risk surgery at a limited number of other

sites

Urgent/Emergency/Acute Medicine An emergency service acting as one (sites/centres/ ambulances)

Some hospitals to retain major emergency admitting services. Other linked hospitals operating less acute services, without acute surgery.

Linked “emergency floors” - at other identified sites

A virtual “corridor” taking patients to the appropriate part of the system as soon as possible

Child Health An ethos of clinical excellence

Guaranteed standards Staff freely transferable A strong voice for health promotion More services networked across hospital groups

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The current proposals envisage two levels of hospital provision “red” and “green” (proposals

only at this stage) described in the following diagram:

4.3 Local Commissioning Intentions – Bolton Clinical Commissioning Group’s (CCG’s)

Strategy

As the Trust’s predominant commissioner, and partner in the provision of services to the Bolton population, Bolton CCG’s plans have a major influence on the Trust’s own plans. It is essential that these are therefore reflected in the Trust’s underlying assumptions about workload, income, service change and priorities. The following sections provide a summary of Bolton CCG’s strategy and specific changes which will affect the Trust and the wider system of health and social care in Bolton. The Trust has shared the activity and income assumptions underpinning this plan with Bolton CCG, who have expressed support for these projections (see appendix H.26– CCG letter).

4.3.1 Bolton CCG Vision for Health and Care Services The vision for Bolton is for the delivery of integrated care across health and social

care, with primary care at the centre of a remodelled service, which would see more services delivered in a primary care/community settings. The aims are to improve early intervention in identifying and supporting vulnerable and elderly patients to remain independent, minimise their risk of reaching crisis and hospital admission and improve primary and secondary prevention of ill health across the population.

The following principles have emerged from discussions between partners involved in Bolton’s Health and Wellbeing Board:

STRATEGIC CONTEXT

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Patients should receive high quality care which is centred around their needs

rather than the needs of professionals and organisations.

The clients/patient should be empowered to manage their own care and self-care

Services should be local wherever possible

Services should be centralised where necessary (to ensure clinical safety)

Care should be integrated across health and social care in all settings

Services should be accessible, convenient and responsive

Information and communications should be centred around the client/patient not the organisation/professional

High quality care should be accessible quickly regardless of the time or day of the week

Key elements will be:

- reducing avoidable admissions to acute care, and reduction in length of stay in acute care.

- Identification of “at risk” individuals, and appropriate services at “front and back doors” of acute services.

- Changes and improvements to primary care, NHS Community Services and adult social care.

- Changes to the funding model to move investment to out of hospital services.

4.3.2 Bolton’s Integrated Care Model

A multi-disciplinary health and social care team will be based in localities

Patients with multiple long term conditions and/or at high risk of hospital

admission and the frail elderly will be designated a care co-ordinator who will be responsible for developing and co-ordinating the patient’s/client’s care plan.

The multi-disciplinary team will include adult community nurses, social workers,

physiotherapists, occupational therapists, community psychiatric nurses and generic workers.

Supported by community assets which enable people to remain independent, with greater confidence to manage their own care.

A high level vision across Bolton has been agreed, and a detailed implementation plan is in preparation. This has helped to inform the Trust’s longer term service and financial planning described in this strategy.

4.3.3 QIPP (Quality, Innovation, Productivity, Prevention) and Demand Management

The CCG has recognised that the QIPP challenge of providing higher quality, affordable services in the context of local health need and demographic pressures, will require not only greater levels of efficiency in the services they commission but

STRATEGIC CONTEXT

28 AMS/KT/601v8 08.10.13

a “structural” change aimed at providing better alternatives to the hospital care, more prevention and early intervention, and stronger systems of demand management. Current priorities described by the CCG and reflected in Trust plans include:

Improving referral management across the health economy (including Consultant to Consultant referrals) and repatriation/the booking service previously transferred to the Trust.

Developing patient pathways and monitoring adherence to Effective Use of

Resources Policy across the health economy.

Developing opportunities for patients to access pre-operative assessment in primary care.

Reviewing out-patient follow-up care to ensure that appropriate activity

takes place at the most appropriate location.

Reviewing the MSK/orthopaedics pathway and making changes as necessary in line with best practice and eliminate the potential duplication of activity/charging inherent in the current pathway.

Improving efficiency in prescribing and improve the system for management

of use of high cost drugs.

Developing a process for reducing demands on A&E services and streaming of “minors” patients.

Re-procurement of the GP Out-of-Hours Service, currently provided by the Trust.

Developing an approach for risk stratification of patients to enable early intervention and reduce risk of non elective admissions.

Redesigning community therapy, nursing and care services to enable patients to be supported in their own homes or in step up/down facilities.

Creation of integrated teams supporting primary care.

Development of a community geriatrician service.

Supporting a programme to improve quality of healthcare in care homes, and reducing A&E and emergency admission utilisation.

Development of paediatric community nursing services supported by acute community paediatricians, to assess and support GP referrals in the community.

MARKET ASSESSMENT

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In this section: An analysis of the Trust’s strengths, weaknesses,

opportunities and threats (SWOT) An overview of the Trust’s competition (NHS and

Independent Sector) An outline of trends in market share

Key points: The Trust has some significant strengths, and the local

market offers some strong opportunities to build on these. The unknown outcome of ‘Healthier Together’ is a potential

threat, but may also be an opportunity. A significant threat is also the potential for unplanned growth of emergency hospital pressures.

The detailed external service-specific analysis which the Trust commissioned provides a starting point for each service to address its priority development needs. Generally the Trust compares well with local peers but there are clear indicators for development and improvement in some areas.

The Trust’s market share has grown steadily over the last three years and there are identified opportunities for expansion of activity in some specialties.

The service plans, and support strategies outlined in Sections 6, 7, 8 and 9 are a direct response to the analysis of our strategic positioning.

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5. MARKET ASSESSMENT

5.1 Strengths, Weaknesses, Opportunities and Threats (SWOT)

Over recent months, the Trust has reviewed the positioning of the organisation and

its services, to inform its strategic plans and priorities. The key factors which are reflected in this plan are described in the “SWOT” summary below:

Strengths

Weaknesses

Being a vertically integrated hospital/ community provider - giving critical mass and scope to redesign “whole pathways” of care

Having a catchment for the majority of the

Trust’s activity which is the same as Bolton Primary Care and Local Authority services and the Trust is an active partner in local Health/Social Care Forums – including the Health & Wellbeing Board

Being a major hub within GM for the

provision of Women’s and Children’s services

Having a number of recognised “flagship”

services

Strong recent performance on a range of access time and other measures including the outcome of CQC visits

Having a financial deficit Having an inconsistent or poor record in

some indicators of performance The impact of financial turn round on

staff morale, recruitment and retention, and potential loss of key skills/experience

Having some physical capacity

constraints – eg day care, endoscopy, theatres

Having an ageing estate on the hospital site,

not purpose-built for some current standards and with pressures on backlog maintenance

Management capacity and capability to support the breadth of the current operational and developmental/improvement challenge

The hospital is the second busiest emergency receiving site in GM and is located with fast access to Bolton and surrounding areas

Having a good track record in

improvement and service redesign, with an established improvement methodology

Having comparatively strong performance

on a number of organisational measures – staff engagement; reference costs; readmissions, access times, stroke care and cancer services

Being a popular choice for training – consistently top in the area for junior doctor training

Having strong clinical engagement and generally good relationships across the Trust

Having under-developed IT capacity and infrastructure; still dependent on National Programme for IT solutions for its major patient-based systems

Recent events have damaged the

reputation of the organisation locally and with partners and regulators

The Trust does not yet have trauma unit

status which may affect judgements about its future capability as a major emergency hub

Recent external reviews have identified

shortfalls in some governance systems

Some specialties are not currently capable of meeting expected standards for access to 24/7 care

Some smaller specialties may become clinically/financially unsustainable as stand-alone services

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Opportunities

Threats

Having the ability to capitalise on the

benefits of integrated services within a single organisation

Changes in the Pennine group of hospitals

may offer further scope to increase the Trust’s presence as a provider of services for the population of Bury

Local primary/secondary care clinical

relationships are generally good and offer an opportunity to work more closely, maintaining and building confidence in Trust services

Potential to repatriate some elective

activity from the independent sector CATS service when its guaranteed income arrangements expire in 2014/15.

Constructive relationships with

neighbouring Trusts provide a basis for collaborative solutions to some service challenges

Unplanned growth in urgent care and

failure to deflect this from the Hospital could produce unsustainable financial pressure on the Trust and a consequent deterioration in quality and performance

The growth of competition within and

beyond the NHS, supported by processes such as “Any Qualified Provider”, could reduce the critical mass of referrals and income, making some services unsustainable

Continuing reductions in tariff and sustained

cost saving targets on providers in future may be at a level that is not able to be absorbed in the organisation

GM-wide service reconfiguration, within the “Healthier Together” strategy, has the potential significantly to diminish the role of the RBH, with greater centralisation of some services into Salford and Manchester

The development of NHS tariff régime, with more emphasis on packages of care, outcomes and quality-related income, offers an opportunity to capitalise on quality improvement

The ageing population and Bolton’s

growing younger population, and the high levels of health need, represent a source of predicted high demand, albeit that the response will be increasingly targeted at community-based solutions

Staff recruitment and retention will become more difficult, with uncertainty over the future of services in the Trust (particularly hospital services)

5.2 Competition – Hospital Services

The Trust’s hospital service competitors are mainly other providers in the North

West of Manchester, particularly the Wrightington, Wigan and Leigh Foundation Trust (WWLFT) and Salford Royal Hospital Foundation Trust (SRFT). The three Trusts’ hospital services share catchment areas in their boundaries. In terms of DGH-level acute and elective services, these three Trusts provide a comparable range of services. SRFT is a GM-wide provider of some specialist/tertiary services, including renal and neurosciences and level-two cancer services. Both WWL and BFT have areas of specific specialist provision. In Bolton NHS FT this is predominantly women, children’s and neonatal services, and in WWL this includes neurorehabilitation, elective orthopaedic and cardiac catheterisation services.

5.3 External Comparative Review

Over recent months Deloitte has undertaken a detailed comparative review of the relative strengths of local trusts, using a number of clinical, quality, financial and

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access measures.

Overall, the Trust performed at or above peers, with marked strengths in Emergency and women’s/children’s services. This analysis has helped to shape the Trust’s planning intentions set out in following sections.

5.4 Independent Sector

Through the AQP (Any Qualified Provider) process in 2012/13, independent sector providers are now in direct competition in some aspects of Trust services, including Audiology, Podiatry, Diagnostics and Ophthalmology. The impact is being monitored although it is too early to see significant change for the Trust. No further AQP proposals have been notified by local commissioners at this point.

Under a GM-wide contract, Care UK provide some elective referral services for initial consultation and minor treatment. Utilisation of the Care UK contract, which has been in place for three years, has risen from 43% in 2010/11 to 75% in 2012/13 but falling back to 61% in 2013/14. The guaranteed income CATS Contract terminates in 2014/15. Between April 2010 and March 2013 independent sector referrals for Bolton PCT residents as a proportion of all elective referrals rose from 7.6% to 12.6% (down from a peak of more than 16% in mid 2012). Around 9% of all Bolton CCG admissions are in the independent sector.

The Trust’s strategy is based on maintaining improvements and developing capacity in key financially beneficial services in order to sustain and build market share where clinically appropriate.

5.5 Market Share

During April 2012 to February 2013 the Trust received 75% the elective admissions and 93.8% of the non elective admissions attributable to Bolton PCT. This is an increase in market share for both elective and non elective admissions.

Specialties that have increased their market share in elective admissions are General Surgery, Urology, Orthopaedics, Haematology, Paediatrics and Elderly Medicine. In non elective admissions, the Trust experienced an increase in the specialties of Obstetrics, Paediatrics, General Surgery and General Medicine.

Market Share for Bolton Population

Period Elective Admissions Non Elective Admissions (excluding Well Babies)

Apr 10 to Mar 11 73.2% 92.5%

Apr 11 to Mar 12 72.8% 92.9%

Apr 12 to Feb 13 75.0% 93.8%

CLINICAL SERVICES STRATEGY

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In this section: A clear statement of the services we plan to provide The assumptions underlying our plans The specific challenges and planning priorities relating to

each area of our service portfolio

Key points: Our future is in:

- integrated care for the Bolton population; - prevention and early intervention; - major A&E, medical and surgical emergency receiving services (at the RBH site); - Continuing to develop as a hub in Greater Manchester for women’s and children’s services - providing a range of planned diagnostic and treatment services.

We have built this plan on the assumption that: - we will provide broadly the same range of specialisms; - each service will demonstrate financial and clinical viability and achieve top quartile efficiency.

Required service and capital developments outlined in the service plan are also assumed in the financial plan.

The priorities we have described in each area of service address the Trust’s most significant challenges, arising either from current performance or from the external changes envisaged over the next three to five years. Given the assumptions contained in the Trust’s ‘base case’, the Clinical Services Strategy set out in the following pages is both realistic and affordable.


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6. Clinical Services Strategy

6.1 Our Core Business

It is clear that the Trust’s clinical services strategy must provide a realistic response to four fundamental factors:

The over-riding imperative to provide services that are high quality, safe, effective and which provide a good experience for patients and their carers, and the population as a whole.

The need to achieve and maintain a financially sustainable future for the Trust and the local health economy.

The re-shaping of local health and social care services to prevent ill health and enable much more care, when it is needed, to be provided outside hospital, particularly for older people and people with long-term conditions .

Reconfiguration of hospital services across Greater Manchester (“Healthier Together”).

The Trust, supported by Deloitte, has undertaken a comparative analysis of the positioning of its services, and in particular, its acute and hospital services. Taken together with the emerging local and Greater Manchester strategic plans, this has led the Board to re-affirm the key elements of its Clinical Service Strategy:

Our Future Services Why?

Bolton NHS FT will build on the advantages of being an integrated provider of local hospital and community-based health services to deliver, with our partners, the very best care for Bolton patients throughout their healthcare journeys. We will focus on ensuring the best care for frail elderly people and people with long term conditions, outside hospital, through design and delivery of effective pathways of care.

This fits entirely the Bolton-wide vision for the future of local services – providing multi-disciplinary care through integrated teams of professionals, working across traditional organisational boundaries and enabling more specialist care outside hospital.

Prevention, early intervention and keeping people healthy is central to why we are here, as well as to provide excellent care for people who need treatment

The Trust provides a wide range of preventative/early intervention services for both adults and children. National and local population trends and resultant pressure on services demands that much greater emphasis is placed on services which keep people well.

Royal Bolton Hospital will remain a major provider of A&E and emergency access services

The Trust remains one of Manchester’s busiest medical and surgical emergency receiving sites. Its geographical location, healthcare demand in its catchment area, the presence of


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a large and specialist women’s and children’s services all support the Trust’s vision of a future continuing to be a major emergency care centre in the configuration of services across Greater Manchester.

The Trust will continue to develop as a centre of excellence for Women’s and Children’s services, remaining one of Greater Manchester’s hubs for those services

After five years of planning and major capital investment and successful implementation, from 2011 Women’s/Children’s and level 3 neonatal services in Bolton expanded significantly – now seeing 6,400 births per year, and is one of eight obstetric-led maternity units, and 24/7 paediatric services within the reconfigured services across Greater Manchester. The Trust believes that the specialist centre that is evolving in Bolton remains core to its future.

The Trust will retain and develop a range of planned diagnostic and treatment services which

Can sustain high standards, have critical mass and are clinically viable

Meet the needs and preferences of patients

Make a positive financial contribution and/or

Are essential to sustaining the wider service provision in the Trust

Planned treatment and diagnostic services in the Trust are generally high performing in terms of access time and other quality standards, and, in some instances, are critical independencies with core emergency services. These services also provide valuable access to the local population, both in hospital and community. The Trust’s recent top-level review has provided a framework, identifying areas of potential change but, broadly, the Trust would aim to continue to provide these services, where appropriate, in collaboration with partners in Bolton and beyond.

Note

“Healthier Together” and Manchester-wide hospital service reconfiguration options – how they are reflected in the Trust’s Long Term Financial Plan assumptions. There is no clarity on what the “Healthier Together” process will conclude. Having reviewed the potential impact on the Trust of various outcomes, it has been decided that it would be inappropriate to include any significant change in the base plan. Possible negative (service losses) and positive (service expansion) impacts have been estimated in the downside and upside scenarios described in the plan. Further detail is provided in Section 9.5.2.


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6.2 What Does this Mean for the Trust’s Portfolio of Services?

The Trust’s current service portfolio includes the following:

Medical specialisms

Respiratory Gastroenterology Stroke Diabetes services Cardiology Care of older people Rheumatology Palliative Care

and related hospital and community-based nursing, therapy enablement/ reablement services.

Acute and Elective General Surgery (Adults and Children)

Colorectal Surgery (Including cancer surgery)

Upper G-I Surgery Vascular Surgery Urology

A&E – (Adults and Children)/Emergency Response

A&E Minor Injuries Acute Medicine

Critical Care ICU HDU CCU Ward-based high

dependency

Hospital and Community-based Children’s Services (including School Nursing & Health Visiting)

CAMHS (Child and Adolescent Mental Health Services)

Trauma and Orthopaedics

Obstetrics and Maternity Endoscopy – Symptomatic and Bowel Screening

Neonatal Care

Gynaecology

ENT

Ophthalmology

Oral/Dental Secondary Referral Services

Breast – Symptomatic and Screening

Skin Services

Sexual Health

Cancer Services/Oncology

Pain Management

Other Community-Based

Services

The basis of this plan is the assumption that:

Broadly, the current range of services and specialisms provided by the Trust will be maintained over the planning period.

The high-level viability review of service, recently undertaken, will now be developed into more detailed service-specific implementation plans building on identified strengths, and addressing those improvements that are required to maintain or develop standards of care, and the sustainability of services. In some cases, this will involve higher levels of collaborative working with other providers.


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The “tests” to be applied in each service will be:

- Ability to sustain high standards, have critical mass, and to be clinically viable, including ability to ensure full recovery of relevant CQUINS payments and avoidance of financial penalties

- Ability to meet the needs and preferences of patients - Ability to make a positive financial contribution, and/or - They are essential to sustaining the wider service provision of the Trust

Across the full range of services, continuous effort will be directed to improving the

efficiency as well as the quality of services, in order to achieve the required financial balance. This assumes that all services achieve or exceed upper national quartile levels of efficiency. (Further details are set-out in Appendix H.24 on Efficiency and Cost Improvement).


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6.3 What are the Service Priorities which are Essential to Achieving our Strategy for

Clinical Services?

A.

Strategic Aim: Bolton NHS FT will build on the advantages of being an integrated Provider of local hospital and community based health services to deliver, with our partners, the very best care for Bolton patients.

Strategic Aim: Prevention, early intervention and keeping people healthy is central to why we are here.

The rationale for the amalgamation of community and hospital services in Bolton in 2011

(“Transforming Community Services” - TCS) was that vertical integration would offer the most effective means of providing higher quality and more efficient pathways of care for the local population. The benefits of joining together of hospital and community-based teams, and the redesign of pathways, has already been demonstrated in the development of integrated Stroke, Musculo-skeletal and Children’s Services, and the current implementation of a “virtual ward” in Respiratory Medicine. It was recognised at the time of merger, however, that although the financial benefits from removing duplication of organisational overheads could be delivered to the health economy in the first phases of integration, the full benefits of integrated care systems would be achieved over a longer period, and aligned to a Bolton-wide drive to reform systems of health and social care delivery.

The Trust firmly believes that the health and stability of the organisation will only be effectively secured through full partnership with commissioners, primary and social care providers in Bolton, to bring about a rebalancing of services towards greater community-based management of care. This will not only improve out-of-hospital care but also enable hospital services to sustain high quality specialist and acute referral services for the patients who need them. It is an essential building block for ensuring the effectiveness of urgent and emergency services.

Over the last six months, under the auspices of local Partnership arrangements, the Trust has worked with the CCG and Local Authority to develop a Vision for Bolton’s future health and care system.

An outline of the main elements of that integrated system is given opposite, and a fuller description in the paper at Appendix A.

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Commissioners and Providers are now working together to confirm a more detailed implementation plan by October 2013. The joint governance arrangements are set out below:

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A.2

Strategic Challenges

A.2.1 Demand - Demographic change – local population projections indicate an expected 12.6%

increase in the over-75 population between 2013 and 2018.

- The health status of the Bolton population is generally worse than the national average, and, in some areas of the borough, amongst the worst in the country.

- Both of the above will drive continuing increases in demand. The underlying rate of demand growth assumed for planning purposes by commissioners and Providers is 5.4% for non-elective services and 4.5% for elective services.

- Dementia – the increasing prevalence of dementia as a complicating factor in the care of older people has potential to precipitate or extend periods of hospitalisation for older people.

- End of Life Care – although improved end of life care pathways have been

developed and better processes are now in place to discharge end of life patients with appropriate care and support, the hospital still sees high numbers of end of life patients in their last two days of life.

A.2.2 Making the Transition - Timescales

- Although there is a shared commitment to make the shift to greater community-

based access, it is recognised that a new system cannot be achieved “overnight”. The key elements of transition planning must include workforce, capacity, skills development and changed working practices, having an effective financial régime, enabling greater access to 7/7 services in the community, and enabling “joined up” patient record systems.

- Bolton has been in the forefront of many community-based developments over the last ten years, including the development of intermediate care, delivery of home-based intravenous therapies, and the deflection of certain patient groups from acute hospital admission. It has also recently tested in a limited way, enhanced access to community nursing and therapies for high risk patients, and a system of proactive management of a risk-stratified population of patients from a group of local general practices. Evaluation has been encouraging and plans will focus on “scaling up” over a period of two and a half years: implementation from April 2014.

A.2.3 Making the Transition - Financial Impact

Establishing alternative community services while also handling current patterns of demand for hospital care will require a period of double-running, allowing the adjustment to be planned, tested and embedded. The shift from hospital to community-based activity also has potential to be destabilising financially for the Trust.

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A.2.4 Making the Transition - Infrastructure

- Other health and social care systems which have achieved successful integration,

demonstrate that there are a number of critical enabling factors, particularly:

Shared records/IT systems across patient pathways

Greater access to specialist skills throughout the patient “journey”

Facilities capable of providing access to services closer to home and outside hospital

“Standard work” – common agreed and documented pathways and referral

mechanisms across all agencies and disciplines in the care system.

Although some of these elements are in place in Bolton, some are significantly under-developed, particularly the ability for professionals and patients to share a common and up-to-date view of the care record.

A.3

Strategic Priorities

A.3.1 Ensure that the Trust’s Informatics Strategy is significantly geared to supporting integrated care across the Bolton Community, as well as enabling more effective transfer of information across wider GM networks of care. (Informatics Strategy, Section 8.2)

A.3.2 Ensure workforce development plans support expansion of provision and new patterns of working in the community. (Workforce development – see Section 8.3)

A.3.3 Confirm with commissioners the basis for funding of community services in future, to enable a financially viable service model, assuming cost and volume contracting for community services from April 2014, transitional funding for at least six months, and 50% of released acute care costs to be redirected to community services within the Trust. When fully implemented it is projected that approximately 4,600 non-elective admissions will be averted. (Further detail provided at Section 9.4.2.)

A.3.4 Ensure full input to joint governance and programme management arrangements.

A.3.5 Continue to support front-line teams to design and implement new ways of working.

A.3.6 Agree with Commissioners the future role of the proposed extended Community Geriatrician service.

A.3.7 Ensure that the Trust’s (and health economy’s) Estates Strategy reflects the needs of greater community-based and integrated care. (see Section 8.1)

A.3.8 Effective delivery of the Trust’s plan for Emergency/Urgent Care (see Section

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6.3(B)) B. Strategic Aim: Royal Bolton Hospital will remain a major provider of A&E and Medical

and Surgical emergency access services B.1 Where do we start from?

Royal Bolton Hospital remains one of Manchester’s major emergency receiving sites,

seeing 128,920 A+ E attendances in 2012/13, the second busiest in Greater Manchester. 26% are ambulance arrivals.

The hospital provides emergency services for adults and children. It handles 5200 emergency general surgical admissions per annum. The fourth busiest in GM (after Oldham, Stockport, Central Manchester).

27% A&E attendances and 33% emergency admissions (excluding Obstetrics) are of non-

Bolton residents.

Over the last three years, the Trust has worked consistently to improve pathways of care for emergency attendances and admissions. This has resulted in steadily reducing lengths of stay (with medical specialties’ performance amongst the best in the region) and improving clinical outcomes, including improved hospital mortality rates.

Key developments have included:

- Improved patient flow processes, Respiratory Medicine, Stroke, Gastroenterology, Complex Care

- 7/7 consultant presence in A&E, Respiratory Medicine, Gastroenterology, Cardiology

- Introduction of a Clinical Decision Unit, 2012

- Closure of town centre Minor Injuries Centre in July 2012 and combined services

at the RBH

- Expanded access to community-based treatment rooms, 2011

- Improved pathways to domiciliary & residential intermediate care, from 2011

- Increased ward-based high-dependency care

- Implementation of a single-point of access for emergency referrals, 2012

Improvements across A&E, hospital and community pathways have enabled the Trust, in the last year, to achieve and sustain the 95% four-hour target. Performance in 2012/13 was 96.9%. The Trust’s median time for people attending A&E was 118 minutes, compared with a North West average of 128 minutes and England average of 137 minutes. Similar improvements have been seen in achievement of Acute Stroke access standards.

In services such as Stroke and Cardiology some specialist treatments have been centralised, and the Trust works within wider networks, operating referral and step-down pathways in collaboration with other providers.

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B.2 Strategic Challenges

B.2.1

Maintaining and Improving Access and Quality

- 49% of all medical and surgical emergency admissions are people aged over 65.

Demographic change has potential to create pressure on the system. The success of plans for improved integrated care and better systems of early intervention is fundamental to maintaining the future quality of emergency/urgent services.

B.2.2 Compliance with Best Practice

- The Trust has not yet been designated a Trauma Unit within the Greater Manchester Trauma Network. The Trust can, however, demonstrate a high level of compliance with trauma unit standards and is seeking assessment.

- The Trust is not able to meet standards for 24/7 on-site senior medical presence

in General Surgery.

- Despite improved lengths of stay and outcomes in Orthopaedics, the Trust fell short of the 36-hour access-to-theatre standard for hip fracture – achieving 54% in 2012/13.

B.2.3 Manpower

- In common with other units, it has not been possible consistently to fill middle grade doctor posts in A&E.

B.3 Strategic Priorities

B.3.1 Fully implement in 2013/14 the changes currently in hand:

Co-location of GP out-of-hours services with other emergency services on

the RBH site (to be agreed with Commissioners)

Roll-out of community-based redesign of 7/7 nursing/therapy support to people at risk of admission or extended length of stay

Implement the “virtual ward” for designated respiratory conditions

Sustain the Single Point of Access service

Implement redesign in hospital-based assessment and primary care referral

screening across the current Bolton Community Unit (BCU) and Clinical Decisions Unit (CDU)on the RBH site

Ensure agreed systems operate to reduce delayed transfers of care,

including for non-Bolton patients.

Sustain and develop the “OPAL” initiative for complex elderly patients, providing intensive specialist Geriatric Medicine input to initial assessment,

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enabling more effective deflection to community-based care for approximately 10% of these patients.

Further develop the successful surgical Enhanced Recovery Programme

which has been shown to reduce length of stay and improve the quality of patient outcomes and experience.

The full-year potential bed day saving from the above initiatives is estimated to be approximately 10,600.

B.3.2 Work with Commissioners, GPs and other providers, to realise benefits of reduced

admissions and reduced length of stay, from a range of admission avoidance/ early intervention initiatives, including:

Implementation by Greater Manchester West Mental Health Trust of the “RAID” initiative to provide early assessment, intervention and support to patients whose dementia places them at risk of extended length of stay and readmission. (To be fully effective from January 2014 – to be confirmed)

Primary care-based admission avoidance measures Ambulance service “Pathfinder” deflection initiative Increased primary care engagement with local nursing homes.

The estimated full-year impact of these initiatives is a deflection of 400

admissions, and hospital bed-day saving of 4,200.

It is anticipated that hospital activity will be steadily reduced toward 2008/09 levels, enabling the Trust to minimise the impact of the 70% reduction in tariff which applies to activity above 2008/09 levels.

B.3.3 Collaborate with other providers in the North West Sector of Manchester to design an out-of-hours model to deliver compliance with standards for 24/7 on-site senior medical General Surgical cover.

B.3.4 Implement from Quarter 3 2013, arrangements to provide a comprehensive G-I bleed rota.

B.3.5 By December 2013 develop a workforce plan for A&E/Emergency Care which exploits skill mix and other options to maintain safe and effective senior medical and other specialist input.

B.3.6 Co-locate ICU and HDU – included in the Trust’s Capital Programme (see Section 8.1)

B.3.7 Regularly review and continue to develop the Trust’s Major Incident and Emergency Response plans.

B.3.8 Achieve Trauma Unit status (or equivalent, as determined by Greater Manchester Commissioners), by April 2014.

B.3.9 Review and redesign inpatient pathways, to achieve upper quartile performance in length of stay in surgical specialities, and further improvements in Medical pathways.

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C. Strategic Aim: The Trust will continue to develop as a centre of excellence for Women’s

and Children’s Services

C.1 Where do we start from?

The Trust provides full consultant-led obstetric services, midwifery-led maternity care, Level 1, 2 and 3 Neonatal Care, 24/7 Paediatric A&E and Inpatient and Medical and Surgical Services, and Gynaecology, Child and Adolescent Mental Health Services and a range of community-based nursing and therapeutic and prevention services for children. The Trust is also the principal provider of Sexual Health Services in Bolton and Wigan.

Separate resident medical consultant rotas for Paediatrics and Neonatal Care were established on 2011 when the Trust saw a major expansion of service, becoming one of eight sites in Manchester providing full obstetric and 24/7 Paediatric Services, and one of three GM Level 3 Neonatal Services. These changes took place as a result of GM’s conurbation-wide reconfiguration of services – “Making it Better” (MiB).

23% of all attendances at Bolton’s A&E Department are under-16’s (26,500 in 2012/13).

There is an active and strong Community Paediatric Service base, offering a range of specialist services and targeting areas of greatest deprivation in Bolton.

Following “Making it Better” (Greater Manchester service reconfiguration), Bolton’s catchment population for these services expanded to include areas of Salford and Bury. The number of births has risen from 4,637 in 2009/10 to 6,361 in 2012/13.

In 2011 hospital and community children’s services in Bolton also came under single management with the implementation of “Transforming Community Services”. Overall, the Trust performs well on objective measures of clinical outcomes and patient experience.

C.2 Strategic Challenges C.2.1

Inpatient Paediatric Capacity

With the implementation of Women’s and Children’s hospital service expansion in 2011, children’s medical, surgical and assessment and observation beds were brought together in a single 38-bedded ward area. Pressure on these beds has increased leading, at the busiest times, to the transfer out of some children and the cancellation of some elective cases. At the same time, there is a possibility that the unit will see more referrals from Salford’s short-stay Paediatric Unit in future.

C.2.2 Children’s Surgery

Maintaining high quality children’s surgery on site is important to supporting the high paediatric emergency workload as well as elective demand. Some elective surgery in Bolton is provided in partnership with the Central Manchester Trust, but the Trust retains specialisms in Orthopaedic and General Surgery for children, and a strong paediatric anaesthetic capability. With the retirement in coming years of paediatric specialists in General Surgery and Orthopaedics, the Trust may lose the ability to sustain these elective services.

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C.2.3 Safeguarding and Looked After Children

Recent years have seen a marked rise in Safeguarding referrals, and staff involved in

increasing numbers of care plans for children on the Child Protection Register. The department does not yet meet standards set down for the numbers of “designated” Safeguarding doctors.

C.2.4 Children’s Population Projections

The number of children (0-14) in the Bolton population is projected to increase from 55,300 in 2013 to 59,500 in 2018 (7.6%), placing a steadily increasing demand on local hospital and community services. Within these trends, the number of children with neurodisabilities is also rising as a result of better survival rates. This is reflected in the complexity of cases managed by community paediatric staff.

C.2.5 Clinical Negligence Scheme for Trusts (CNST) and Obstetric Service Standards

The Trust is currently rated at CNST Level 1 (range is 0-3). Its aim is to achieve highest standards in all external measures of service quality. CNST re-assessment has been deferred pending confirmation of the new processes and measures to be used in the accreditation system.

C.2.6 Obstetric Pathways, Salford and Bury

The Trust currently provides out-reach antenatal clinics in Salford and Bury for women

referred to Bolton from those districts. It is clear, however that the tariff for such attendances does not adequately cover the costs and the service is sustaining a significant deficit.

C.2.7 Financial Régime – Obstetric Services

The Trust has identified that the costs of providing services to the levels and standards in

the Greater Manchester-wide specification are not affordable within the income currently available for this activity, resulting in an overall cost pressure. This has prompted local review of the specification and the payment structure.

C.2.8 Outpatients Accommodation

Despite recent significant capital investment in Women’s and Children’s Services, the Children’s Outpatients Department at Royal Bolton Hospital was not included in this development and is currently provided in out-of-date accommodation, lacking modern facilities. Likewise, accommodation in the Children’s Centre at Halliwell is of a poor standard.

Both the Sexual Health and Child and Adolescent Mental Health Services are also currently based at the RBH, but are considered appropriate for relocation to a community setting.

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C.3 Strategic Priorities

C.3.1 Optimise Paediatric In-patient Capacity

- Continue to harness the benefits of hospital/community service integration, to

foster an increased capability for community nursing services to deflect potential non-elective admission, and support post-acute care at home

- Improve availability of paediatric rapid access clinics

- Work with Commissioners to develop local integrated referral and assessment for children

- Extend paediatric bed capacity, using a part of Ward F5.

- Succession plan for consultant posts with a specialism in Paediatric Surgery and Orthopaedics.

C.3.2 Together with Service Commissioners, ensure that Safeguarding is resourced sustainably,

in the light of increasing referrals.

C.3.3 Maintain high standards in Obstetrics, within the income available - Agree with Commissioners a financial model which is affordable, to support standards within an agreed specification, in relation to the midwife to birth ratio, ratios of midwife care in labour, and levels of consultant presence in Central Delivery Suite.

C.3.4 Resolve the costs of providing antenatal services for Salford and Bury residents - Agree with Commissioners alternative funding arrangements for the Salford antenatal service, or agree to withdraw the service, seeing all Salford and Bury women in clinics at Bolton.

C.3.5 Extend Gynaecology market share - Undertake detailed review of opportunities to

extend the coverage of the Gynaecology service, potentially working with neighbouring providers.

C.3.6 Relocate appropriate services to the community

- Relocate Children’s Outpatients from RBH and from Halliwell Children’s Centre to Breightmet Health Centre in 2014/15

- Relocate Sexual Health services from RBH to Bolton One in 2014/15

- Look at options for relocation of Child and Adolescent Mental Health Services to a

community base, 2015/16. (See Estate Strategy – Section 8.1)

C.3.7 Maintain access on the RBH site to essential clinical specialisms to support emergency and elective paediatric services, and 24/7 consultant-led Obstetric services – these include:

- Critical Care - General Surgery - Diagnostics

- 24/7 A&E - Anaesthetics - Orthopaedics

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D

Strategic Aim: The Trust will retain and develop a range of planned diagnostic and treatment services

D.1 Where Do we start From?

The Trust provides a broad range of elective, outpatient, inpatient and day case Medical and Surgical specialisms in hospital and community. 39% of admissions to Royal Bolton Hospital are elective, and 80% of these are day cases. The Trust is also a provider of two major screening programme; the Bowel Cancer Screening Programme which serves Bolton, Wigan and Salford; and Breast Screening which serves the populations of Bolton, Bury and Rochdale.

Planned diagnostic imaging services are provided at Royal Bolton Hospital, and at the Bolton One Town Centre health facility. Imaging modalities provided by the Trust include plain film, CT, MR, Ultrasound, Mammography and related sub-specialities. Some routine imaging sessions are available to patients outside the normal working week.

Bolton’s Laboratory Medicine Department has been at the forefront, nationally, in redesigning ways of working to improve quality, turnaround times and efficiency.

Within Bolton, Care UK provide Clinical Assessment and Treatment Service (CATS) under a GM-wide contract, which comes to an end in 2014/15. This provides outpatient-level services in General Surgery, Gynaecology, ENT, Urology, Orthopaedics and Endoscopy.

The Ophthalmology Department is one of Greater Manchester’s busiest providers, with a range of sub-specialisms, a 7/7 acute referral service, and supporting the local Diabetic Screening Programme, and Neonatal Services. The Trust also provides out-patient services in Salford.

Level 1 cancer diagnosis, treatment and follow-up care is provide for the following tumour sites; working in collaboration with specialist referral centres across Manchester and Lancashire:

Gynaecology Urology Upper G-I Haematology

Skin Head and Neck Lung

The Trust provides Level 2 care, including complex surgery, for

Colorectal Cancer Breast Cancer

Oncology services are provided on the RBH site in collaboration with Christie Hospital.

Capacity has recently been increased to provide more local access to Chemotherapy.

Performance against elective access time (18-week) standard has steadily improved, achieving compliance overall and in each specialty in May 2013. Compliance with cancer waiting time targets is also high.

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The following elective services are regarded as important in sustaining strong Emergency

and Women’s & Children’s services on the RBH site:

Gynaecology Endoscopy Colorectal Surgery Upper G-I Surgery ENT Anaesthetics

Urology Orthopaedics Paediatrics Imaging, Laboratory Medicine and

Pharmacy

D.2 Strategic Challenges

D.2.1

Capacity constraints in Endoscopy have led to extended diagnostic waiting times

and breaches of the 6-week target. This has been partly mitigated by short-term measures using third party providers, as well as in-house capacity initiatives. The Joint Advisory Group on Endoscopy (JAG) has withheld full accreditation of the service pending confirmation of plans to expand capacity. JAG accreditation is essential to continued ability to provide sustainable screening as well as symptomatic endoscopy services.

D.2.2 The “Healthier Together” initiative, including the GM-wide review and planned recommissioning of cancer services, will demand that the Trust maintains high-level of compliance with Cancer IOG (Improving Outcomes Guidance) standards. Current levels of compliance are good but there are outstanding issues relating to access to Acute Oncology and Oncologist participation in cancer multi-disciplinary teams in Bolton. The Churchill Cancer Unit is nearing full utilisation. Some future expansion of chemotherapy will be provided via a visiting mobile unit run by Christie Hospital, on the RBH site.

D.2.3 In 2014/15 the GM-wide contract for CATS (Clinical Assessment and Treatment Services) which offers services in Bolton via Care UK will terminate. This may offer greater opportunity for Trust services to compete to reprovide some of this activity.

D.2.4 There have been some improvements in the efficiency Out-Patients services, including reduction of new-to-follow up rates. Continuing work in this area is a part of the financial turnaround plan. Did Not Attend (DNA) rates however remain high, at 9.5% for first attendances and 10.3% for follow up attendances in 2012/13.

D.2.5 The Any Qualified Provider (AQP) initiative and other commissioner tendering processes have the potential to erode market share for hospital and community-based services, although also offering opportunities for extending the catchment of some services where a viable business case can be made by Trust Services.

D.2.6 There is potential for a greater proportion of out-patient activity to be provided in community-based accommodation, allowing access closer to home and enabling rationalisation of accommodation at RBH.

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D.2.7 While overall theatre utilisation is comparatively efficient, there are further

opportunities to optimise theatre and Day Unit capacity. This is a workstream within the current efficiency plan, and will also enable fewer cancellations.

D.2.8 Elective inpatient workload continues to be affected at the height of winter pressures, despite the significant reduction in the number of medical “outliers” which has been achieved over the last three years.

D.3 Strategic Priorities

D.3.1 All specialities to achieve at least top quartile performance in their elective length

of stay and day case rates.

D.3.2 Confirm plans for the expansion of Endoscopy capacity by a further three rooms, in line with workload and income projections (see Estates Strategy, Section 8.1)

D.3.3 Expand Bowel Screening to include flexible sigmoidoscopy screening, in line with national requirements, from 2014/15.

D.3.4 Maximise out-patient capacity and efficiency through continued measures to

reduce DNA rates.

D.3.5 Relocate more outpatient services to community facilities – priorities include Paediatrics and Skin Services and Orthopaedic Outpatients from Minerva Day Hospital to Bolton One [in 2014/15], (dependant on final agreement with the CCG).

D.3.6 Achieve IOG compliance by expansion of access to acute oncology consultant sessions and nursing support on the RBH site; the Trust meeting the costs of the expanded service, from the termination of pump-priming monies in 2014/15; and appraise options for an expanded Cancer Unit, in the light of the site-wide space utilisation review.

D.3.7 Implement further measures to protect elective bed capacity, particularly in Winter, including, from Autumn 2013, the relocation of some Orthopaedic theatre sessions to Wrightington Hospital and by ensuring that at least one ward area is available to allow short-term flexing of bed capacity in winter.

D.3.8 Prepare a detailed business case for potential extended role of local Bolton Breast Services within a future GM-wide service reconfiguration, including a review of options for the expansion and improvement of the current Breast Unit accommodation.

D.3.9 Adopt a more proactive approach to marketing elective services, particularly those judged to have growth potential, and ensure that robust systems are in place to respond to AQP or other tendering processes.

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A STRATEGY FOR HIGH QUALITY CARE

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In this section: A summary of the Trust’s key aims for continuously

improving the quality of its care The enabling developments required to support those aims

Key points: Aims:

- reduced mortality; - preventing infection and harm; - responding to, and learning from harm and errors; - enhancing the patient’s experience.

Essential enabling developments: - Informatics and IT - Staff engagement and training - Estates and Facilities

Our service plan (Section 6) and governance arrangements (Section 11) are complementary with our priorities for improving our quality of care.


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7. A STRATEGY FOR HIGH QUALITY CARE

7.1 Our Aims for the Quality of Care in Our Organisation

We aim to rise to the challenge of delivering safe, effective and compassionate

care. To do this we must maintain and strengthen the focus on quality in the face of financial and organisational challenges. We must respond to the call from Francis, Keogh, Cavendish and Berwick to listen to and act upon the concerns of our patients, their carers, their families and our staff. We will achieve this by putting patients at the heart of how we do things, actively seeking and demonstrating learning from their feedback We will work on a portfolio of projects that will lead to demonstrable improvements in outcomes, safety and patient experience. Each project workstream will involve patients and staff from across the organisation, working systematically, sharing best practice and using proven quality improvement tools to ensure consistent delivery of improved performance.

7.2 Key Ambitions

Reduce mortality

- Over the last five years our mortality rates have fallen year-on-year. The work of the Mortality Reduction Group will continue with the goal of no needless deaths in this organisation.

Key target - Bolton to be in the top 10 NHS Hospitals as measured by risk adjusted mortality comparisons.

Reduce harm

- We will focus on a range of infections including Clostridium Difficile (C.Difficile), hospital acquired pneumonia and surgical site infection. We will be vigilant in monitoring, and learning from critical analysis of cases, and using evidence-based prevention measures.

Key target - Deliver 50% year-on-year reduction in hospital acquired infections, including C.Difficile

Improve outcomes

- We will regularly produce and review relevant outcome measures for our clinical services. This information will be compared with other organisations and used to drive continuous improvement.

Key target - Share benchmarked clinical outcome data in a transparent fashion with patients

Improve patient experience

- Providing a good quality patient experience requires actively seeking, responding to and learning from patient feedback. We will provide opportunities for feedback for all patients and carers.

Key target - Develop a patient and public-designed system for responding to and learning from complaints and patient feedback.

We will build on current strong foundations of good quality care and improvement methodology. We will deliver quality improvement by working with and empowering patients and staff across the organisation. Quality improvement is seen as essential to the financial sustainability of the Trust. We believe that


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high quality care need not cost more. Getting it right first time, and moving care out of hospital when appropriate is less costly and the right thing to do for patients. Cost improvement programmes will only be implemented after a full quality impact assessment.

7.3 Organisational Culture/Workforce Capability

An organisation’s culture is derived from the behaviours and attitude of the

workforce and leadership. A consistent theme that has emerged from our Big Conversation staff engagement events, is the deep motivation of staff to do their best for the people who need their care. The personal and professional commitment of the workforce are reflected in our organisational values. (Our Core Values and behaviours are set out in Section 3.3) We will continue to embed the Core Values of our Trust into all aspects of organisational life, as the foundation for the delivery high quality care The Trust will also continue to build capacity and capability in our workforce so that our staff have the skills to deliver high quality care, aiming for zero harm to patients, and looking for opportunities, everyday, to improve what we do Enabling the delivery of highest quality care is at the heart of all our leadership programmes, including those for clinical and medical leaders. All our programmes evaluate the development of leadership skills throughout, tracking productivity and quality improvements made by each participant. Continuing to build and develop our coaching culture will also provide additional support to help individuals and teams to realise their potential, working with staff to enable them directly to influence how things are improved in their areas of work.

7.4 Delivering the Strategy

Delivery of our strategy will be through programme management of a series of workstreams, designed to underpin our primary aim - to provide caring, safe and effective services. The workstreams have been identified following wide consultation with clinical and managerial staff and governors. They comprise four quality improvement workstreams targeting specific areas of improvement in clinical outcomes, patient safety and patient experience. They are underpinned by three enabling workstreams. Each workstream builds on existing work, but adds focus and stronger performance management to ensure delivery. Each workstream will have a clinical leader, supported by a multidisciplinary team and with a wide range of capability and experience drawn from across the organisation. Key members of each team will be patients and members of the public.

Each workstream will use a systematic approach and proven quality improvement tools, including valuestream analysis, strategy and policy deployment, visual management and Plan-Do-Study-Adjust (PDSA) cycles, to build continuous improvement. Teams will scope their work at initial workshops, using external experts where necessary; produce a clear description of their purpose and their


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plans; hold learning sessions and summits; and scale-up and spread their learning. They will identify their priorities, the resources required, set out ambitious annual goals, and define and track the relevant measures of progress.

7.5 Our Goals

Reducing Mortality – Our Goals

Bolton to be within the top 10 NHS hospitals for risk-adjusted mortality

rates. Bolton to be a leading unit for low perinatal mortality.

Preventing Infection and Harm – Our Goals

Strengthen the infection control culture, with infection control champions

in all clinical areas. Deliver 50% year-on-year reduction in C. Difficile rates. Deliver target reduction in other forms of healthcare acquired infection. Ensure compliance with antibiotic policy across the Bolton healthcare

community. No “Never Events” (specific types of healthcare-related harm, or potential

harm, that are judged to be “zero tolerance”). Achieve levels of quality care that ensure maximum reward from CQUINS

funding, and year-on-year improvement in Harm Free Care performance (relating to catheter care, prevention of falls, prevention of pressure ulcers and the assessment of patients for blood clots.

Responding to and Learning from Harm and Errors – Our Goals

Ensure that the Trust’s complaints process is fit for purpose. Encourage the reporting of clinical incidents. Develop an innovative system for sharing learning from harm and errors. Ensure there is a strong patient and public voice in all aspects of learning

from harm and errors.

Enhancing Patient Experience – Our Goals

Develop a matrix of patient experience scores across the organisation to give a clearer picture of variation in the way that patients experience our services.

Share best practice and develop action plans to address our weaker areas. Continue to improve the coverage of the Friends and Family test and use

the results to shape our improvements – aiming for the best scores in the country from our patients.

7.6 Essential Enabling Workstreams

Informatics, IT and Information Driving Better Care

Develop performance reports that flow from ward to Board level.

Deliver IT strategy to facilitate safe, effective care.


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Improve IT access across the organisation. Build our presence on the web to ensure that patients can access

performance data and advice.

Staff Engagement and Training

Develop an organisational culture of patient focus and quality improvement.

Ensure 100% compliance with mandatory training that includes quality improvement techniques.

Introduce learning passports. Recruit staff who are caring and compassionate. Develop a no-blame culture. Establish multiprofessional quality forums in each specialty to engage all

levels of staff.

Estates and Facilities

Ensure that patient areas allow privacy and dignity and are functionally suitable and economically used.

Ensure easy patient access. Ensure that the design and maintenance of our estate and facilities

support safe care.

7.7

Measurement

To judge progress against the goals we have set ourselves in this strategy we will monitor a range of relevant indicators. These will be incorporated into an integrated report, so that they can also be seen in the light of other aspects of organisational performance (such as workforce, operational delivery and finance). The measures which are relevant to tracking improvements in the quality of care, include:

High-level indicators which relate to the Trust’s key priorities for clinical quality. These will be set on an annual basis and will form the basis of the Trust’s Quality Account.

Commissioning for Quality and Innovation (CQUINs) targets – these

targets include national, regional and local CQUINs which are agreed with commissioners on an annual basis, as part of our service contracting negotiations. Achievement of relevant standards results in the payment of quality incentive monies.

“Advancing Quality” – these are groups of indicators related to

compliance with best practice (also called “care bundles”), relevant to the management of specific conditions

Quality Schedule measures – these are other measures of quality, agreed

with our commissioners as part of the Trust’s contractual commitments

Trust clinical quality indicators – other Trust-specific indicators that are established at Trust, Division and service level as part of our internal planning and performance systems


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Early Warning Matrix – A report bringing together a group of location-

specific indicators on workforce and the quality of care, which may identify potential “hot spots” for further action.

The Trust will also use a wide range of other evidence, observations, user-feedback, audits and external assessments, to assess the quality of its services.

7.8 Governance

All workstreams will be overseen by the Trust’s Quality Improvement Team. This will be jointly chaired by the Medical Director and Director of Nursing. The seven workstream leads and a patient representative from HealthWatch will support them. The team will provide leadership, articulate goals, ensure that the work is communicated widely and establish and performance manage the full programme of work. The Quality Improvement Team will report to Trust Board via the Quality Assurance Committee.

[Full Strategy document attached at Appendix B]

ENABLING STRATEGIES

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In this section: A summary of our plans for

- The Estate - Informatics - Workforce (Full documents appended – Appendices C, D, E)

Key points: The over-riding objectives of our enabling strategies are:

- providing an infra-structure and workforce that is fit for future, supporting the Trust’s service strategy; - improving quality, safety and the experience of patients; - enabling best value for money.

The Estate priorities: - enabling more work to shift from hospital to community premises; - better facilities for urgent/emergency care; - expansion of endoscopy capacity; - achieving highest ratings for estate condition, utilisation and management; - reducing backlog maintenance and costs and generating income.

Informatics priorities: - integration of hospital and community systems; - development of an electronic patient record; - introduction of electronic document management; - supporting mobile working; - improving business intelligence.

Workforce priorities: - building integrated teams, across hospital and community services - improved management and leadership; - developing the unqualified workforce; - strong performance assessment framework; - staffing levels commensurate with needs of patients; - developing roles and contracts of employment to meet service need.

The costs associated with enabling strategies are assumed in the long term financial plan, and our service plans (Section 6) demonstrate the way in which these workstreams support specific areas of change.

ENABLING STRATEGIES

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8. ENABLING STRATEGIES

8.1 Estate Strategy – The Challenge

8.1.1 Description of the Estate

The Land and Building assets that the organisation owns are currently valued at £110.8m. The Trust currently operates from a range of premises that vary from new high quality, fully functional premises, (that are not fully utilised), to Victorian properties that offer poor quality in terms of decoration, comfort, functional suitably and backlog maintenance risks. Data on the performance of the organisation’s estate is limited. The Trust has undertaken property appraisal in terms of Building, Engineering, Statutory Safety and Fire Safety on an annual basis, which contributes to identification of Backlog Maintenance cost. The Trust has one of the highest Backlog Maintenance costs within the region, currently £23.9m which is risk adjusted to £11.95m. The risk adjusted figure is a calculation that takes into account high and significant risk whilst also acknowledging future maintenance cost for moderate and low risk. The Trust has an ageing building services engineering infrastructure, with identified high and significant backlog maintenance risk. The current main air cooled chilled water plant that provides refrigeration for the main Theatres Air conditioning plant has reached the end of its operational life. The equipment regularly fails causing operational difficulties in the operating theatres. Much of the heating infrastructure is inefficient and the current coal boilerhouse equipment is very maintenance-intensive, and performs poorly in terms of carbon emissions. During the past five years significant investment has been directed into the Electrical infrastructure which has included the procurement of modern stand-by generators. This is an area that could be explored to provide the Trust with potential income. In previous Estate Strategies reference has been made to disposal of the South East Sector of the site, however little progress has been made. Currently the large areas of the former Print and Laundry buildings are vacated and surplus to requirements. Areas such as Children’s Outpatients and Minerva Day Centre offer poor accommodation and these buildings have significant backlog. Premises within the community such as Halliwell Children’s Centre and Westhoughton Health Centre also provide poor facilities for patients. In past two years the Trust has located some services into the health economy “Flagship” premises of Bolton One and Breightmet Health Centre. These two

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premises provide high quality functionally suitable environments. However, a recent week long space utilisation survey highlighted poor levels of occupation within these centres. In some areas, rooms had utilisation rates of below 30%. There has been some interest from a potential developer and another NHS Trust to buy land in the South East sector of the RBH site for health / social care related projects. A valuation of the South East Sector of the site has recently been undertaken by the District Valuation Officer. Land prices within the Farnworth area remain depressed, and the current valuation for this site is £2.75m The large proportion of the acute clinical services are located on the main spine of the hospital. Ward accommodation between A and D blocks was built in the early part of the twentieth century and this accommodation has been converted from original nightingale wards. Although B1 ward has recently been upgraded and A4 ward is currently undergoing refurbishment, the remaining accommodation feels tired and in need of refurbishment, although some work to provide improved infection prevention in these wards is currently ongoing. Recent upgrades to the Maternity Unit have provided first class Neonatal / Special Care and Central Delivery Unit facilities. However the remainder of the Maternity complex has high risk backlog maintenance issues in terms of fire safety and asbestos. Many of the ward area environments are looking tired, and these areas can be very drafty during the winter months due to poorly fitting metal window frames. The Major Development accommodation of E, F and G Block, which was built in 1996, remains in a generally good condition, although some of the engineering plant and equipment is in need of refurbishment, as this equipment is reaching the end of its normal life-cycle.

8.1.2 Our Objectives for the Estate Strategy

The Estate Strategy is designed to achieve three objectives:

To have an estate which is fit for the future, supporting the Trust’s

service strategy

To have an estate which enhances the quality and safety of care and the experience of patients and staff

To have an estate which enables best value for money

The dominant drivers for change are from:

- New patterns of service, especially the shift of more care out-of-hospital

and into community setting

- Rising standards

- The potential for new ways of working enabled by digital technology

- The drive for greater levels of efficiency

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- Rapidly changing market conditions which demand greater flexibility of

providers.

8.1.3 Where Do We Want to Be?

The performance of the estate has traditionally been measured in terms of NHS Property appraisal criteria and Patient Environment Action Team (PEAT) / Patient Led Assessment of the Care Environment (PLACE) inspections. However these assessments don’t take into account functional suitability, space utilisation and energy performance. As a result the Trust has limited information on the performance of the estate. Recent space utilisation audits of areas in Bolton One and Breightmet Health Centre provide an indication that as an organisation, we do not manage our space well. The new Estate Strategy must deliver a Trust estate that truly supports the Clinical Service Strategy, in premises that are functionally suitable, welcoming, comfortable and are utilised efficiently and effectively. The new (under-utilised) facilities of Bolton One and Breightmet Health Centre provide an opportunity to relocate services that currently operate within buildings on the Royal Bolton Hospital site, with poor environment and maintenance-related problems. This will allow a rationalisation of the hospital estate, allowing the demolition of buildings with low occupancy or with significant backlog maintenance issues, and enabling the sale of surplus land within the South East sector of the Royal Bolton Hospital. All acute clinical services need to be located on the main spine of the Royal Bolton Hospital site, with a building service engineering infrastructure that is highly efficient, cost effective and fully meeting our carbon emissions reduction commitment. As part of the future, the Estates Capital Investment Programme will include the refurbishment of patient and public areas along the main spine of the hospital. During the next five years, the Estate Strategy and associated capital investment will deliver improvements in the following, achieving the highest possible performance for each standard of the NHS Land and Property Appraisal model, as set out below.

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Physical Condition Achieve Standard B Sound – operationally safe

and exhibits only minor deterioration.

Functional Suitability Achieve Standard A Very satisfactory – no change needed.

Space Utilisation Achieve Standard F Fully used – a satisfactory level of utilisation.

Quality Achieve Standard B Facility requiring general maintenance investment only.

Statutory requirements Achieve Standard A Building complies with all statutory requirements and relevant guidance.

Environmental Management Achieve Standard B 56 to 65 GJ per 100 cubic metres.

The Estate Strategy will also include two local additional criteria in which performance will be measured and improved these being:

Backlog Maintenance – Zero risk-adjusted Backlog Maintenance within five years. Planned Preventative Maintenance – 95% compliance for Maintenance Programme

for each of the 15 identified critical systems i.e. water safety, fire safety and electricity, to be achieved as soon as possible, within three years.

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8.1.4 Building Blocks! A Summary of the Developments in the Estate Strategy

Enabling the Trust’s Service Strategy

Integrated Care, prevention

and early intervention Reduced lengths of stay enabling

released ward space More outpatient access at Bolton

One, Breightmet Health Centre (HC) and Lever Chambers.

A major provider of emergency

services on the RBH Site Proposed extension of emergency

receiving area, using vacated out-patient space

Proposed co-location of GP Out-of-Hours service at RBH

Co-location of ICU/HDU Winter/decanting ward capacity

available

A centre of excellence for

women’s and children’s services Relocation of Children’s Out-

Patients to Breightmet Health Centre

Upgrade works – PAMU (Princess Anne Maternity Unit)

Extension of paediatric inpatient area (part of F5 to be included in paediatric ward)

Relocation of CAMHS to a Community base

Relocate Sexual Health Services from RBH to Bolton One

Provider of planned diagnostic

and treatment services Extend Endoscopy Unit by three

rooms Review of Breast Unit requirements

for potential expansion Extended space for Chemotherapy Relocate Therapies accommodation

from RBH to Bolton One

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Improving Quality and Safety

Standard of facilities

Plans to achieve:

- Physical condition rating “B” - Functional suitability, target “A” - Space utilisation, target “F” - Quality, target “B” - Statutory requirements, target “A” - Environmental management, target “B”

Patient/visitor amenities

Exploring potential for private

sector involvement in on-site patient hotel development

Potential retail expansion and re-development of main entrance, RBH

Surfacing and barriering of all car parks

Negotiate good public transport links

Participate in MacMillan Cancer Information Centre development

Staff accommodation and

facilities

Potential on-site hotel development

Relocate Education Centre to main spine, RBH

Reprovision of conferencing and catering facilities (linked to hotel development)

Reducing Costs/Generating Income

Backlog Maintenance

Disposal of surplus land, RBH

Vacate poor health centre accommodation in the community

Address £11.9m risk-adjusted backlog maintenance

Improve engineering infrastructure on RBH site

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Improving space

utilisation/reducing overheads

Intensify use of high quality “flagship” developments across Bolton, and liberate and remove sub-standard accommodation elsewhere

Relocate (to N Block) and reduce back office accommodation

Improving estates engineering

infrastructure

Engage an energy partner to provide guaranteed energy savings based on upgrade of building services engineering infrastructure

Upgrade current boiler house to include electrical generation

8.1.5 Estate Investment

The treatment, in the long-term financial plan, of investment supporting the

Estate Strategy is described at Section 9.6.2.

A copy of the full Estate Strategy is included at Appendix C.

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8.2 Informatics Strategy

8.2.1 Background

In 2011, Amor Group was commissioned to review Informatics at the Trust. The key

recommendations made by Amor, were endorsed by the Board of Directors in October 2011, including the proposal to integrate the IT and Information functions into a single department and investment in Electronic Patient Record (EPR) and Electronic Document Management (EDMS).

Since the publication of the Amor report an Informatics Strategy (June 2012) and Informatics Investment Strategy (draft August 2013) have been developed by the Trust. The Informatics Strategy and Informatics Investment Strategy seek to support the Trust in the challenges it faces, and to enable it to meet its service objectives. The strategy also aims to align Informatics development at BFT with the objectives set by the Department of Health’s Power of Information strategy for Informatics in the NHS (May 2012) which highlights technology as a critical enabler in the provision of care and delivery of improved quality and more efficient services in the future.

8.2.2 Summary of the Trust’s Informatics Strategy (2012)

The Trust’s Informatics Strategy described action in the following areas:

Realising the benefits from Integration of IT and Information functions, to create a single Informatics Department.

A shift from data production to the provision of “business intelligence” (for example, improved analysis for Divisions and Board reporting).

The development of a Clinical Informatics approach supporting improved efficiency and care quality, and mitigating clinical and information governance risks, with a long term aim of an Electronic Patient Record.

The use of mobile technology to support improved care and to enable more flexible working. Innovative use of mobile technology would enhance BFT’s ways of working and also support recovery of CQUINS and the avoidance of contract penalties, through more complete and timely data recording.

Responding to the challenges of commissioning and competition: including service level reporting, and providing integrated systems for GPs.

The integration of Community and Hospital Services IT infrastructure and information reporting

Improving the IT infrastructure, in particular investment in wireless networking, PC upgrades and investment in mobile working.

Improving business engagement by the Informatics Team, to ensure IT systems are used to optimise business processes and care delivery, and to ensure that management information is as accurate, timely and relevant as possible.

Investment in an Informatics Service Delivery capability that provides a professional, service level-based support function, based on best industry practice, and with a commitment to continuous improvement.

Implementing best practice Informatics governance, including standard project management, programme and service management methodologies.

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8.2.3 Progress to date

The Trust has made significant progress towards these five-year objectives:

Completion of the integration of the Information Analysis and IT functions.

Outline Business Specifications and Outline Business Case prepared for electronic document management system (EDMS) and a joint OJEU (European Union) procurement with Pennine Acute is at the competitive dialogue stage.

Outline Business Specification and Outline Business Case for EPR has been produced and investigation is under way into routes to market for EPR with partner Trusts in Great Manchester.

Significant progress made towards an integrated performance dashboard for the organisation.

8.2.4 IT Investment Strategy/Long Term Financial Plan

The treatment of the IT Investment Strategy within the Long Term Financial Plan is described in Section 9.6.3.

A copy of the Informatics Strategy is included at Appendix D

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8.3 Workforce Strategy

8.3.1 Background

The Trust launched its initial Workforce Strategy in April 2007 following a number of focus groups held with staff and members of the then Public and Patient Involvement forum to ensure that it responded to the real issues for our staff and our patients. This strategy was then updated with our current Workforce Strategy 2012 – 2017, which was agreed at the Board of Directors in June 2012. In April 2013 the Board received a document “Workforce Strategy 1 Year On”. The purpose of the paper was to update the Board of Directors on the Workforce Strategy and to provide assurance the strategy remains relevant and fit for purpose.

8.3.2 Five Key Workstreams

The strategy is currently based on five work streams which underpin a series of key activities, supporting the development of an integrated workforce; that is fit for purpose and able to deliver safe, high quality care to patients, as was recently re-emphasised in the Francis Report. The five work streams are as follows:

Effective leadership, engagement and accountability Versatility of the Workforce to realign and transform as services

change. Flexible working – matching capacity with demand. Embedding the Values into the way we do things. Caring for the Health and Wellbeing of our staff.

The aim is to create a great place to work, and the best place to receive care, by ensuring that our staff feel valued, respected and proud. Never has it been more important to continue the work to engage staff in the things that affect them, alongside implementing new ways of working and managing reductions in the size of the workforce.

The Workforce Strategy sets out the Trust’s vision, aims and objectives in creating a ‘Great Place to Work’. It outlines how the Trust aims to achieve its objectives through the development of a responsive and flexible workforce, improving the quality and experience of the patients and continuing to develop workforce capacity and capability.

8.3.3 Priorities

It is vital that focus is maintained on creating a ‘Great Place to Work’, particularly

during a time of transition and transformation. To this end the Trust will:

Renew focus on the development of a transformational approach that creates one culture for the integrated organisation, working with teams across the community and hospital in developing more streamlined care

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pathways, fusing together the skills of the workforce and developing a more blended team focused on high quality patient experiences.

Assess current leadership, management capability and competence and

in light of the assessment, review and improve the current provision of management, leadership development programmes and learning opportunities, ensuring alignment with the gaps highlighted in the review.

Increase focus on the development of the unqualified workforce,

including Healthcare Assistants and Practitioners in respect of core basic skills, alongside appropriate attitude and behaviour.

Continue to build and consolidate a high performing and inspirational

culture; ensuring staff are clear what is expected of them in relation to performance delivery standards and improvement, developing a performance assessment framework which links incremental progression to performance, recognising and rewarding accordingly.

Ensure staffing levels are appropriate and take into account the

dependency and acuity of patients, together with more robust and effective rostering of staff, to ensure the right skills at the right time in the right place.

Continue to develop roles and contracts of employment to support the contingent workforce concept.

8.3.4 Measuring Progress

In order to measure the success of the strategy, the Trust will continually review

key workforce performance indicators. These measures will be developed during the life of the strategy to reflect the maturity of integrated performance management and information systems.

The aspiration is to be able to measure the contribution of the workforce at corporate, clinical directorate and individual levels and to relate these to the aim of providing high quality care in an efficient and productive manner.

One of the key measurements of success will be evidence of continuous improvement from the Annual Staff Survey.

8.3.5 Workforce Key Indicators

Around 73% of costs is attributed to staff pay, including temporary bank and

agency spend. The current make-up of the workforce is predominantly female (85.7%). Part-time employees equate to 44.9% of the workforce.

The Trust currently has a staff turnover rate of 13.1%. This is higher than recent

years due to the large scale turnaround programme reducing the number of staff employed. Temporary staff expenditure across the Trust is a significant problem and has been

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the focus of significant attention to improve the current position, including consolidation of ward nursing establishments through recruitment of additional permanent staff during the first half of 2013/14 The Trust has a rolling 12 month sickness absence rate of 4.67%. There are some specific areas where sickness is above the Trust target of 3.75%, notably in the healthcare assistant and nursing & midwifery workforce. Plans to improve this position are managed through the divisional performance review process.

8.3.6 Workforce Numbers

The workforce impact of the income changes forecast and the cost improvement

programme is substantial. A summary of the expected workforce for each year of the plan is shown in section 9.5.5. A bridge analysis showing the basis of the changes is shown in appendix H.19. This represents a reduction on base year of 2014/15 4.9%; 2015/16 9.9%; 2016/17 12.6%; 2017/18 16.5%; 2018/19 20.2%. It should be noted that the Trust’s average annual staff turnover is 11%. The scale of workforce change modelled should be achievable without additional redundancy costs.

A copy of the Trust Workforce Strategy 2012/17, “Valued, Respected and Proud”,

is attached at Appendix 8.3

8.4 “Back Office” Services

All non-clinical support services and corporate services are under continuous

review, using benchmarked comparisons and looking at opportunities to capitalise on partnerships and/or potential commercial ventures that may improve quality and/or the cost of these services. The option of third-party contracting will be considered where this may be appropriate.

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FINANCIAL ANALYSIS AND PLANS

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In this section: An analysis of financial performance over the last three

years, including the causes of the Trust’s deficit position The projected income and expenditure position of the Trust

over the next five years, with a clarification on the assumed factors affecting the plan

The projected activity plan, underlying the financial assumptions

The profile of assumed cost improvements over the next five years

Projected investment in capital and the Estate Strategy, and in the Informatics Strategy

A summary of cash reconciliation and loans reconciliation across the five years of the plan

A projected service continuity rating A calculation of the ‘downside’ risk

Key points: The Trust has plans which will return the organisation to

surplus by the end of the next financial year. Our plans support an improvement in our service continuity

rating from two in 2014/15 to three in 2016/17. The plan assumes that levels of income and efficiency are

sufficient to support the Estate and IT investment required (see Section 8).

The plan assumes a cost improvement of £73.1m over five years (4.7% overall).

The plan assumes a level of income improvement (average 0.6%) over the lifetime of the plan, which is considered realistic.

It is considered that the financial modelling of the ‘base case’ plan is cautious but realistic. The ‘downside’ case models the potential impact of lower than expected activity and some under-delivery of cost reductions, together with cost pressures 25% higher than expected, and the potential cash impact of failure to secure a loan or PDC finance. The analysis of this scenario and mitigating measures demonstrates that financial viability can be maintained.


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9. FINANCIAL PLANS 9.1 Summary of Financial Plans The five year financial plan that supports the delivery of the Trust’s strategy demonstrates how the Trust will

Return to surplus in 2014/15

Achieve a continuity of service rating of two in 2014/15 rising to three in 2016/17

Achieve sufficient surplus to finance the Estates Strategy

Achieve sufficient surplus to finance the IT Strategy

Effectively manage downside risk To do this the Trust will deliver

Income and cost improvements of £73.1m over five years

Support is required to facilitate the plan

Temporary public dividend capital issued by the end of 2013/14 to be made permanent

Agreement of non-commercial loans or public divided capital to facilitate the Estates and IT strategy

It should be noted that agreement of public dividend capital to facilitate the Estates and IT strategy would improve the Trust’s continuity of services rating allowing a three to be delivered in 2015/16 and a four in 2016/17 and beyond.

The income assumptions in the plan are prudent and have the support of the Bolton Clinical Commissioning Group.


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9.2 Historic Position 9.2.1 Statement of Comprehensive Income

2010/11 2011/12 2012/13Revenue £,000 £,000 £,000Operating revenue from continuing operations (patient care) 187,519 252,710 256,820 Other operating revenue 23,516 30,419 25,288 Operating expenses (214,086) (291,060) (306,391)Operating surplus (deficit) (3,051) (7,931) (24,283)Finance costs:Finance Income 56 33 31 Finance costs (381) (791) (853)Finance expense - unwinding of discount on provisions (11) (9) (26)Public dividend capital dividends payable (3,859) (3,625) (3,110)Net Finance Costs (4,195) (4,392) (3,958)

Surplus/(Deficit) (7,246) (12,323) (28,241)

Impairment of fixed assets (9,192) (10,446) (4,541)Provision for redundancy costs 0 0 (9,300)Underlying Trading Surplus/(Deficit) 1,946 (1,877) (14,400) As can be seen from the table above the Trust’s financial position has significantly deteriorated since the 2010/11 financial year whilst at the same time its income has increased substantially. The income increase results primarily from the fact that in the 2011/12 financial year, as a result of the national Transforming Community Services (TCS) initiative, the Trust took on the community services formerly provided by NHS Bolton. In addition to this the Trust became a regional centre for excellence for women, children and family services under the Greater Manchester “Making It Better” (MIB) initiative. Throughout the 2011/12 financial year a surplus of £1.7m was forecast. However on completion of the 2011/12 accounts a deficit of £1.9m was revealed before accounting for asset impairments of £10.4m. As can be seen the deficit grew in 2012/13 to an underlying deficit of £14.4m. The Trust also made provision for £9.3m of redundancy costs in that year. The subsequent investigation into this position identified the causal factors as follows:

Significant deficit on services taken on under TCS Significant deficit on the services involved in MIB Failure to deliver the required cost improvement on other services

All of this was underpinned by significant failures in financial process and governance such that the Board was not aware of the potential for a deficit until the 2011/12 accounts process began. During the 2012/13 year the Trust’s financial risk rating fell to one, the lowest possible level. The Trust was found to be in breach of the terms of its authorisation by Monitor.


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9.2.2 Cost Improvement Performance

2010/11 2011/12 2012/13

Division £,000 £,000 £,000Adult Acute 2,047 1,605 1,156 Elective Care 2,811 4,640 3,209 Family Care 1,417 1,028 2,292 Corporate 971 5,803 1,985 CIP Total 7,247 13,076 8,642 CIP % 3.4% 4.6% 3.1% Whilst significant cost improvements have been delivered in the three years analysed, apart from in 2011/12 these are below the 4% efficiency requirement built into the national tariff and are therefore consistent with a deteriorating financial position. 9.2.3 Statement of Financial Position Extract At the start of the period examined the Trust did not have the level of cash reserves accumulated by many Foundation Trusts. This lack of financial resilience meant that as the financial position declined the Trust had to begin receiving cash support from the Department of Health (DoH) in order to continue to operate. This cash support came in the form of temporary Public Dividend Capital (PDC).

Statement of financial position extract 2010/11 2011/12 2012/13

£,000 £,000 £,000 Cash balance 7,643 7,639 300Temporary Public Dividend Capital 0 0 (9,000)


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9.3 Income And Expenditure Plan 9.3.1 Forecast Statement of Comprehensive Income The table below summarises the planned income and expenditure position of the Trust over the next five years. The plan allows for the Trust to return to surplus in 2014/15 and attain a continuity of services rating of three by 2016/17.

2013/14 2014/15 2015/16 2016/17 2017/18 2018/19Forecast Plan Plan Plan Plan Plan

Start Point Plan £m £m £m £m £m £mPbR income 160.7 164.3 161.2 158.0 156.8 155.6Other income 92.1 92.8 91.6 90.4 89.3 88.1Income reductions -4.3 -2.3 -2.3 -2.3 -2.3 -2.3Divisional Income 26.0 25.7 25.3 25.0 24.7 24.4Total income 274.5 280.5 275.8 271.1 268.4 265.7

Pay -197.6 -188.7 -180.7 -173.9 -170.9 -168.3Non-Pay -76.6 -76.6 -76.0 -76.3 -76.1 -75.7Risk Reserve 1.0 -3.2 -4.1 -4.1 -4.1 -4.1Depreciation -5.2 -6.1 -7.1 -7.4 -7.4 -7.4PDC / Interest -3.9 -4.3 -4.8 -4.8 -4.8 -4.8Total Expenditure -282.3 -278.9 -272.7 -266.6 -263.3 -260.2

Surplus/(deficit) -7.8 1.6 3.1 4.6 5.1 5.5

EBITDA 1.3 12.0 15.0 16.8 17.3 17.7EBITDA % 0.5% 4.3% 5.4% 6.2% 6.4% 6.6%

Income / Cost Improvements 15.2 22.2 16.4 13.6 10.9 10.9Income / Cost Improvements % 5.5% 7.6% 5.9% 5.0% 4.1% 4.1%

Continuity of Services Rating 1 2 2 3 3 3


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9.3.2 Statement of Comprehensive Income – 2013/14 Analysis The Trust’s financial plan for 2013/14 targeted a reduction in the annual underlying deficit from £14.4m in 2012/13 to £7.8m. It is also planned to achieve run rate balance by the end of the financial year. To deliver this income and cost improvements of £16.2m are required. As at the end of month five of the year it is forecast that the deficit target will be achieved. The necessary income and cost improvements will be delivered as follows:

The Trust also has a plan to deliver run rate balance by the year end. This involves bringing forward elements of the 2014/15 income and cost improvement plan into the end of 2013/14. For clarity in this long term plan these actions are assumed to happen at the “stroke of midnight” on the 31st March 2014. Hence the opening position for 2014/15 is stated in the following bridge analysis as £8.8m, which is the £7.8m deficit for 2013/14 with the non-recurrent balance sheet adjustment added back. The Trust is planning to receive a further £17.3m of temporary Public Dividend Capital in 2013/14 giving a total balance of £26.3m received since the Trust went into deficit.

2013/14 Forecast £m Income Improvement 1.6Turnaround cost improvement 9.0Tactical cost improvements to be made recurrent 2.4Release of risk reserve - recurrent 2.2Balance sheet adjustments - Non Recurrent 1.0Total 16.2


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9.3.3 Statement of Comprehensive Income – Bridge Analysis The following bridge analysis is intended to “tell the story” of the financial plan for the next five years.

1) Start position – this is the brought forward income and expenditure position from the previous year. As noted above the start position is an £8.8m recurrent deficit.

2) Generic pressures – these describe the forecast impact of global efficiency requirements for NHS providers as contained in the national tariff. These are composed of 1.3% for tariff deflation and 2.7% for cost inflation. The cost inflation is calculated as follows:

1.0% pay award per year 1.7% incremental drift and other pay pressures

3.3% non-pay inflation

3) Specific pressures – these are the revenue costs for the Estates and IT strategy which are described more fully in section 9.6.2 and 9.6.3. These costs are forecast to be in excess of that that can be contained with the generic amounts identified above.

4) Income and activity changes – this captures the income and cost effects of changes in

activity forecast over the life of the plan. These are described in more detail in section 9.4.1. It is assumed that variable and semi fixed costs will be triggered through these changes (82% of income).

5) Income and cost improvements – this shows the impact of the income and cost improvements that are required to deliver the planned surplus in light of the above pressures. It also shows the value of additional improvement required to generate an appropriate risk reserve. It is assumed that this risk reserve will be required each year as part of the management of downside risk. It is important to note that over the life of the plan the average income and cost improvement is 5.4% which has been shown through research to be a sustainable level of change in the health sector. The cost element of this over the life of the plan is 4.7%. Details of how these income and cost improvements will be delivered are contained in section 9.5.

6) In year position – this is the high level statement of income and expenditure for each year over the life of the plan. It should be noted that although a 2% surplus is planned by year five the continuity of service rating will be a maximum of three because it is assumed that the IT and Estates strategies will be financed through loans which has the effect of reducing the rating from that which would be achieved if they were financed by non-repayable Public Dividend Capital.

It should be noted that no specific costs are forecast for redundancy or other restructuring costs through the course of the plan other than that already provided for. This is on the basis of a deliverability analysis which shows that the scale of change inherent in the plan can be delivered through effective management of staff turnover. “Winter Plan” funding has not been included in the bridge. It is assumed that will be available non recurrently from each year from either the NHS England or Bolton Clinical Commissioning Group.


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Statement of Comprehensive Income - Bridge Analysis

2014/15 2015/16 2016/17 2017/18 2018/19 1) Start Position £m £m £m £m £m

Income 274.5 280.5 275.8 271.1 268.4 Expenditure -282.3 -278.9 -272.7 -266.6 -263.3 Surplus (Deficit) -7.8 1.6 3.1 4.6 5.1 Add back non recurrent -1.0 0.0 0.0 0.0 0.0 Surplus (Deficit) - recurrent -8.8 1.6 3.1 4.6 5.1

2) Generic pressures £m £m £m £m £m Generic Cost Pressures -7.8 -7.6 -7.3 -7.2 -7.1 Tariff Deflation -3.6 -3.7 -3.6 -3.6 -3.5 Total generic pressures -11.4 -11.3 -11.0 -10.7 -10.6 Total generic pressures % -4.2% -4.0% -4.0% -4.0% -4.0%

3) Specific pressures £m £m £m £m £m IT -1.5 -1.7 -1.1 -0.1 0.0 Estates -0.9 -0.8 0.2 0.4 0.0 Total specific pressures -2.4 -2.5 -0.9 0.3 0.0 Total specific pressures % -0.9% -0.9% -0.3% 0.1% 0.0%

4) Income and activity changes £m £m £m £m £m Income 2.3 -1.4 -1.4 0.5 0.5 Expenditure -0.3 1.1 1.2 -0.4 -0.4 Total income and activity changes 2.1 -0.2 -0.3 0.1 0.1 Total income and activity changes % 0.8% -0.1% -0.1% 0.0% 0.0%

5) Income and cost improvements £m £m £m £m £m Costs 14.0 16.0 13.2 10.5 10.5 Income 7.3 0.4 0.4 0.4 0.4 Additional to generate risk reserve 4.1 0.0 0.0 0.0 0.0 Assumed use of risk reserve -3.2 -0.9 0.0 0.0 0.0 Income and cost improvements 22.2 15.5 13.6 10.9 10.9 Income and cost improvements % 7.9% 5.5% 4.9% 4.0% 4.1% Income element % 2.6% 0.1% 0.1% 0.1% 0.1% Cost element % 5.3% 5.4% 4.8% 3.9% 3.9%

6) In Year Position £m £m £m £m £m Income 280.5 275.8 271.1 268.4 265.7 Expenditure -278.9 -272.7 -266.6 -263.3 -260.2 Surplus (Deficit) 1.6 3.1 4.6 5.1 5.5 Surplus (Deficit) % 0.6% 1.1% 1.7% 1.9% 2.1%


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9.4 Income Analysis 9.4.1 Income bridge

The above bridge analysis gives a detailed reconciliation of the income changes in the plan. The income plan has been developed in conjunction with Bolton CCG. A letter from the CCG accountable officer confirming that CCG’s belief that these assumptions are reasonable and affordable is attached at appendix H.26. The column named “bridge category” shows which line the entry appears in the overall bridge analysis in section 9.3.3. The individual line items are explained below

1) Tariff deflation – it is forecast that the national tariff will reduce by 1.3% per year over the life of the plan.]

2) Income deflation – Divisional income – it is forecast that non healthcare contract income will be under pressure due to the financial position of other NHS providers. It is assumed to reduce by 1.3% a year.

3) The pressure for increased hospital activity because of demographic change has been calculated using the ONS population projections for Bolton.

4) The pressure for increased community activity because of demographic change has been calculated using the ONS population projections for Bolton.

5) The pressure for increased activity as a result of advances in medicine has been forecast based on historic trends.

6) The reduced demand for acute services as a result of the community service integration strategy has been included based on the assumptions made by Bolton CCG.

2014/15 2015/16 2016/17 2017/18 2018/19 £m £m £m £m £m

Line Category Opening Healthcare Income 274.5 280.5 275.8 271.1 268.4 1) Generic Tariff deflation @ 1.3% -3.3 -3.3 -3.3 -3.2 -3.2 2) Generic Income deflation - divisional income -0.3 -0.3 -0.3 -0.3 -0.3 3) Activity Activity growth - Demographic - Acute 2.0 1.8 1.8 1.8 1.9 4) Activity Activity growth - Demographic - Community 1.0 0.8 0.9 0.8 0.8 5) Activity Activity growth - Residual - Acute 2.5 2.6 2.6 2.6 2.6 6) Activity Integration - savings - Acute -1.9 -3.8 -1.9 0.0 0.0 7) Activity Integration - investment - Community 2.0 2.0 0.0 0.0 0.0 8) Activity Stroke reconfiguration -1.0 0.0 0.0 0.0 0.0 9) Activity QIPP - additional to integration -4.7 -4.7 -4.7 -4.7 -4.8 10) Activity Non Elective - Marginal Rate 1.4 0.0 0.0 0.0 0.0 11) Improve PBR Data quality 0.8 0.0 0.0 0.0 0.0 12) Improve Contractual performance 2.0 0.0 0.0 0.0 0.0 13) Improve Community - Activity catch up 1.9 0.0 0.0 0.0 0.0 14) Improve Community - Staffing ratio catch up 1.1 0.0 0.0 0.0 0.0 15) Improve CQUINs to 100% 1.5 0.0 0.0 0.0 0.0 16) Activity Community - IT Infrastructure transfer 0.5 0.0 0.0 0.0 0.0 17) Activity Community - Impact of £1.9m IT invest 0.4 0.0 0.0 0.0 0.0 18) Improve Community - fixed staffing ratios 0.4 0.4 0.4 0.4 0.4 Plan for the year 280.5 275.8 271.1 268.4 265.7


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7) The investment in community services provided by the Trust required to deliver the change identified in 6) is forecast. A six month lead time (double running) has been assumed.

8) Further reconfiguration of Greater Manchester Stroke services will reduce our income by

£1m from 2014/15 onwards.

9) Bolton CCG is assuming acute sector demand reductions to this value as a result of their work on Quality, Innovation, Prevention and Productivity (QIPP).

10) The impact of Bolton CCG QIPP and the community integration work is forecast to mean that demand for non-elective services will reduce so that the Trust will be operating below the 2008/9 baseline for the non-elective marginal tariff (30%). The activity adjustments calculated in 6), 8) and 9) are calculated at full tariff, this adjustment is required to show the income impact at the correct marginal rate.

11) PBR Data Quality – the income impact of improved coding of clinical activity as described in the medium term efficiency plan section.

12) The income improvements resulting from improved performance of the healthcare contract in respect of access targets and infection control such that the Trust does not get contractual penalties for these issues as described in the section on the medium term efficiency plan.

13) Bolton CCG have agreed in principle to retrospectively fund activity increases in community services which have previously been unfunded as a result of the block contract community services has operated under since 2011/12. This is part of the overall strategy to ensure that the Trust’s community services are financially viable going forward as described in appendix H.26.

14) Bolton CCG have agreed in principle to refund tariff deflation on community services where fixed staffing ratios are required as part of the service specification. This is part of the overall strategy to ensure that the Trust’s community services are financially viable going forward as described in appendix H.26.

15) The Trust is forecasting that it will fully achieve the quality improvement targets set through “CQUINs” over the next five years.

16) Bolton CCG have agreed in principle to fund IT costs the Trust has incurred as a result of changes in the CCG / CSU’s location.

17) Bolton CCG have agreed in principle to fund the revenue costs of the IT investments necessary to drive clinical and productivity improvements in the community.

18) Bolton CCG have agreed in principle to not levy tariff deflation on community services where fixed staffing ratios are required as part of the service specification. This is part of the overall strategy to ensure that the Trust’s community services are financially viable going forward as described in appendix H.26.


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9.4.2 Activity Plan The income assumptions shown are underpinned by the following acute sector activity assumptions which include the full impact of demand increases which are more than offset by the commissioner community integration and QIPP plans.

Activity type 2014/15 2015/16 2016/17 2017/18 2018/19A&E 114,427 111,872 109,893 108,518 107,071Day Cases 25,011 24,753 24,484 24,202 23,907Elective IP 6,738 6,676 6,611 6,543 6,472Non Elective IP 35,384 32,678 31,103 30,728 30,362OP - First 88,180 87,261 86,303 85,301 84,248OP - FUPs 142,646 141,149 139,588 137,957 136,241OP - Proc First 13,925 13,777 13,622 13,461 13,292OP - Proc FUPs 29,973 29,672 29,357 29,028 28,681Delivery Episodes 5,756 5,684 5,610 5,533 5,453Antenatal Pathways 6,267 6,189 6,108 6,024 5,937Postnatal Pathways 5,041 4,979 4,914 4,846 4,776Excess Bed Days 16,038 15,899 15,754 15,600 15,438Other 100 103 105 107 110Total 489,487 480,691 473,453 467,851 461,986

A specialty level analysis of these assumptions is shown at appendix H.16.


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9.5 Income And Cost Improvements 9.5.1 Income and Cost Improvement Plan

The Trust has developed a long term efficiency plan which can be found at appendix H.24. This plan is based on a series of benchmarking exercises which have enabled the Trust to form a view as to what efficiencies are possible over the next five years. A summary of the output of this work is shown below:

2014/15 2015/16 2016/17 2017/18 2018/19 TotalICIP Summary £,000 £,000 £,000 £,000 £,000 £,000Income 7,303 367 367 367 367 8,771Cost - Pay 10,797 11,045 10,502 8,083 7,615 48,042Cost - Non Pay 4,100 4,088 2,731 2,450 2,918 16,287Total 22,200 15,500 13,600 10,900 10,900 73,100

Total income and cost improvements % 7.9% 5.6% 5.0% 4.1% 4.1% 5.3%Income improvements % 2.6% 0.1% 0.1% 0.1% 0.1% 0.6%Cost improvements % 5.3% 5.5% 4.9% 3.9% 4.0% 4.7% It is important to note that over the life of the plan the average income and cost improvement is 5.4% which has been shown through research to be a sustainable level of change in the health sector. The cost element of this over the life of the plan is 4.7%. The individual components of the plan are shown in the table below:

2014/15 2015/16 2016/17 2017/18 2018/19 TotalRow Type Scheme £,000 £,000 £,000 £,000 £,000 £,0001) Income PBR Data quality 800 0 0 0 0 8002) Income Contractual performance 2,000 0 0 0 0 2,0003) Income Community - Activity catch up 1,900 0 0 0 0 1,9004) Income Community - Staffing ratio catch up 1,103 367 367 367 367 2,5715) Income CQUINs to 100% 1,500 0 0 0 0 1,5006) Cost - Pay Grade Mix 1,300 1,300 6,500 0 0 9,1007) Cost - Pay Bed Reductions 2,612 3,040 1,300 1,085 0 8,0378) Cost - Pay 30 Day Readmission - to upper quartile 476 200 0 0 0 6769) Cost - Pay Day case rates - to upper quartile 73 0 0 0 0 7310) Cost - Pay Outpatient procedures - to upper quartile 420 200 0 0 0 62011) Cost - Pay Outpatient DNA Rates 410 300 0 0 0 71012) Cost - Pay Other acute staff - productivity 2,200 2,200 1,100 1,045 993 7,53813) Cost - Pay Community - Management costs 575 0 0 0 0 57514) Cost - Pay Community - IT - Travel scheduling 144 754 300 0 0 1,19715) Cost - Pay Community - IT - Record keeping 113 721 300 0 0 1,13416) Cost - Pay Community - Indirect costs @ 2% 195 205 430 215 215 1,26017) Cost - Pay Community - Priority based review 400 0 0 0 0 40018) Cost - Pay Corporate - Priority review 750 0 0 0 0 75019) Cost - Pay Corporate - Staff Efficiency 1,000 769 731 694 660 3,85420) Cost - Pay Sickness rate reductions 300 300 300 300 300 1,50021) Cost - Pay Pay reform - increments 500 0 0 0 0 50022) Cost - Pay Fixed Staffing Ratios 1,629 544 544 544 544 3,80523) Cost - Non Pay Corporate - Consultancy 1,200 0 0 0 0 1,20024) Cost - Non Pay Non Pay - Clinical 0 1,150 1,000 1,000 1,000 4,15025) Cost - Non Pay Non Pay - Non Clinical 2,900 2,600 750 700 700 7,65026) Cost - Pay Provider efficiency assumption - Pay 900 5,413 3,097 8,300 9,003 26,71327) Cost - Non Pay Provider efficiency assumption - Non Pay 0 338 981 750 1,218 3,28728) Cost - Pay Risk Reserve -3,200 -4,900 -4,100 -4,100 -4,100 -20,400Total 22,200 15,500 13,600 10,900 10,900 73,100


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1) Points one to five are all income improvements that have already been described in section 9.4.1

6) Grade mix – the benchmarking work has shown that the Trust’s agenda for change grade mix

is more expensive than the vast majority of other Trusts in the benchmark group. A programme of work will be put in place to address this going forward. Because of the protection arrangements currently in the Trust this will take a number of years to achieve.

7) Bed Reductions – the Trust performs strongly on length of stay in the medical specialties but is less strong in the surgical specialties. By achieving upper quartile performance in all specialties significant savings can be made in the first years of the plan. It is planned that at least two wards will close at the start of the new financial year.

8) Points eight through to 11 describe a range of improvements in clinical process that will yield savings on implementation.

12) Other acute staff productivity - the Trust’s chief operating officer has estimated the level of savings that will be available in theatres, pathology, radiology, medical staff and administrative support staff. £2.2m is expected from these areas in the first year of the plan.

13) Community services – the Trust has a long term financial plan for its community services which has been shared with Bolton CCG and has their support in principle. This plan is available at appendix H.25. It is designed to fit with the health and social service integration work that is currently under way in Bolton. It shows how through a combination of additional income and productivity savings the deficit on community services can be resolved and the services run at a surplus in the later years of the plan. Items 13 to 17 are the individual cost components of this plan.

18) A priority based review of corporate services is underway currently. This review will identify £750k of savings by making major reductions in non-priority areas.

19) Corporate areas not impacted by the priority based review will make a 6.5% reduction in year one of the plan and a 5% reduction each year thereafter. This will be done by implanting transaction processing improvements and implementing shared services with other NHS bodies.

20) Sickness rate reduction – a continued programme of improvements in this area will produce incremental benefits on an on-going basis.

21) Pay reform – increments – it is now possible under the national agenda for change arrangements to make incremental progression performance related. The impact of the implementation of this is expected to yield £500k in year one.

22) Fixed staffing ratios – there are a number of services in the Trust’s hospital services where the service specification requires a fixed ratio of staff to patients. This means that it is not possible to make the tariff efficiency of 4% each year in those areas. Bolton CCG have indicated their willingness to work with the Trust to re-specify these services so that efficiencies can be made whilst ensuring that safe services are delivered. The £1.6m in the first year is the historic impact of this issue over the last two years being resolved.


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23) Action is in place to ensure the costs of management consultancy and senior interims are significantly reduced. This is forecast to save £1.2m in the first year of the plan.

24) Non Pay improvements - the non-pay improvements forecast are relatively modest because of the Trust benchmark position on these costs. Improvements are driven by the estate strategy and procurement practice.

26) Provider efficiency assumption – the long term efficiency plan is derived from benchmarking which is fixed at a point in time. As the Trust moves toward the upper quartile its benchmark peers will also become more efficient so the Trust is in effect aiming at a “moving target”. This is represented in the long term efficiency plan by an assumption that 2.2% per year improvement would be made by other Trusts in the same period giving a value of £30m in total over five years. This value will be identified into operational plans as the long term efficiency strategy is refreshed each year.

28) Efficiencies have been identified sufficient to cover 1.5% downside risk per year over the life of the plan - £20.4m in total. The net amount that must be delivered is £73.1m.

9.5.2 Income and Cost Improvement Plan – Clinical Services Reconfiguration As noted earlier the plan described assumes that the range of services provided by the Trust will remain broadly the same over the life of the plan as they are now. A working describing the basis of the financial judgement involved is at appendix H.22. Essentially if Bolton NHS FT gains services as a result of Healthier Together then there is a potential upside to the plan, this is assessed as £15m additional income with a £2.7m margin improvement. 9.5.3 Income and Cost Improvement Plan – Income Upside The income assumptions used in the base plan are conservative. There are a number of market expansion opportunities for the Trust. In addition there is potential for Bolton CCG QIPP plans to be less effective than expected along with the potential gains under Healthier Together noted above. Appendix H.23 shows a potential income upside of £30.8m by the last year of the plan giving a potential margin improvement of £5.5m. 9.5.4 Income and Cost Improvement Plan – Capacity Impact Significant bed capacity reductions are forecast over the life of the plan as a result of length of stay improvements and reduced demand due to community integration and the commissioner QIPP programme. The Trust currently has 861 beds of all types. This is expected to reduce by 253 by year five of the plan. A specialty level analysis of this change is shown at appendix H.17. 9.5.5 Income and Cost Improvement Plan – Workforce Impact The workforce impact of the income changes forecast and the cost improvement programme is substantial. A summary of the expected workforce for each year of the plan is shown at below. A bridge analysis showing the basis of the changes is shown at appendix H.19. It should be noted that the Trust’s average annual staff turnover is 11%. The scale of workforce change modelled should be achievable without additional redundancy costs.


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2014/15 2015/16 2016/17 2017/18 2018/19Plan Plan Plan Plan Plan

Staff Type WTE WTE WTE WTE WTESenior Managers & Managers 52.80 51.17 49.61 48.13 46.73Medical Staff - Consultants 172.42 161.60 158.11 151.38 145.10Medical Staff - Other Career 37.23 34.89 34.14 32.68 31.33Medical Staff - Reg & Spr 80.01 74.99 73.37 70.25 67.34Medical Staff - Shos & Hos 139.00 130.28 127.47 122.04 116.98Medical Staff - Other Career 1.67 1.57 1.53 1.47 1.41Dental Staff - Consultants 0.24 0.23 0.22 0.21 0.20Dental Staff - Other Career 0.96 0.90 0.88 0.85 0.81Dental Staff - Reg & Spr 1.31 1.23 1.20 1.15 1.10Nurses - Qualified 1,707.36 1,618.43 1,568.41 1,496.16 1,427.95Nurses - Unqualified 18.95 17.96 17.41 16.61 15.85Scient, Therap & Tech Staff 388.44 370.98 362.21 348.48 335.65Scient & Prof Staff 165.20 157.77 154.04 148.20 142.75Prof & Tech Staff 153.05 146.17 142.71 137.30 132.25Other Scient, Therap & Tech 2.58 2.47 2.41 2.32 2.23Administrative & Clerical 799.68 755.50 722.02 684.35 648.78Hca & Other Support Staff 691.52 655.50 635.24 605.98 578.35Maintenance & Works Staff 41.01 41.01 41.01 41.01 41.01Non Nhs Staff (Agency Etc) 179.95 170.27 166.42 159.73 153.48Chairman & Non-Exes 6.00 6.00 6.00 6.00 6.00PAY 3.29 3.29 3.29 3.29 3.29Total 4,642.67 4,402.22 4,267.72 4,077.60 3,898.58

Reduction on base year % 4.9% 9.9% 12.6% 16.5% 20.2% 9.5.6 Income and Cost Improvement Plan - Programme Delivery It is clear from the above that the level of efficiency required over the life of the plan is greater than that that has been delivered by the Trust in the recent past. A robust programme is in place to ensure the scale of change can be delivered. Key differences from previous programmes are noted below:

Internally owned opportunity development Support from Bolton CCG re income solutions Joined up approach with CCG to solve community issues CCG sympathetic re MIB service specification issues Service line approach to maximise clinical engagement Divisional accountability enhanced through revised programme management approach Fast track corporate CIP Legislative change = faster consultation HR policy & pay reform All plans must be in place by the start of the financial year in question – minimal back

loading The following work streams will operate to deliver the plan


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Work stream Exec Lead Key Deliverables Income improvement DoF PBR Data Quality

CQUINs Contractual Performance Improvements Community Income Improvements

Bed Reduction (LOS) COO Length of stay reduction Bed reduction

Workforce policy HR&OD Policy – protection policy Policy – pay awards Policy – incremental progression Policy – grade mix review Policy – Medical Job Planning E Roster

Community Integration COO Community productivity Community integration impact

Elective service lines COO Service line margin improvements Adult and acute service lines COO Service line margin improvements Family care service lines COO Service line margin improvements Corporate costs CEO Priority based review

Reduce consultancy costs 6.5% Efficiency in year one Long term efficiency plans

Procurement DoF Procurement strategy Estates COO Estates strategy Information Technology COO Information Technology strategy A central programme management office will be operated this will be led by the Finance Director. The Programme Board is made up of the Executive Team chaired by the Chief Executive. 9.5.7 Income and Cost Improvement Plan – Financial Governance The Trust has in place a robust finance improvement plan which is aimed at achieving best practice financial governance standards to ensure the delivery of the overall plan. The key objectives of the first year of this plan are as follows:

1) Service and Financial recovery Deliver the 2013/14 financial plan Ensure a robust long term financial plan is in place by September 2013

2) Financial governance improvements

Achieve a score of “Adequate” under the Auditors Local Evaluation Framework by March 14

Reduce the number of red flags under the Board Governance Assurance Framework – Finance Development Module by 50% by March 14

Ensure finance basic processes are rated as Green by March 14

3) Finance skills development Achieve the KPIs set out in the finance directorate development plan Organisation ready for service line management by April 14


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The plan is currently on track to deliver in 2013/14. Annual iterations of the plan will be developed to support the continuous improvement programme. 9.5.8 Income and Cost Improvement Plan – Quality Impact Assessment The benchmarking work used to derive the plan was against all the medium sized acute Trusts in England. There is significant variation in these Trusts’ performance in regards to quality. Key elements of the exercise were run just against those Trusts that were Foundation Trusts and that were Green or Amber Green for governance under the Monitor compliance framework. This exercise showed no material change in the overall opportunities available. From this the Trust has concluded that in principle the savings can be achieved without negative impact on quality. All savings plans will be rigorously quality impact assessed before implementation as part of the process described in 9.5.2.


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9.6 Capital Programme 9.6.1 Summary Capital Programme

2014/15 2015/16 2016/17 2017/18 2018/19£'000 £'000 £'000 £'000 £'000

Buildings - ongoing 3,992 4,992 5,292 5,292 5,292Plant & equipment 1,396 1,396 1,396 1,396 1,396Furniture 39 39 39 39 39Office & IT Equip. 265 265 265 265 265Software licenses 142 142 142 142 142Leased asset 266 266 266 266 266Estates Strategy 5,636 9,009 2,030 0 0IT Strategy 5,800 5,796 1,465 357 357Total 17,536 21,905 10,895 7,757 7,757

A significant capital programme will run over the life of the plan. This is composed of three key elements.

The normal on-going replacement of assets as they fully depreciate. Depreciation of £5m per year is available to finance this. The key elements of this can be seen in the table above.

IT strategy - this will require additional finance- see below Estates strategy – this will require additional finance - see below

9.6.2 Estates Strategy The estates strategy is designed to a) reduce significantly the backlog maintenance risk faced by the Trust by improving space utilisation and thus reducing the estate foot print leading to the disposal of a portion of the site b) improve the Trust’s utility infrastructure to reduce business continuity risk and generate savings. The financial impact of the plan is summarised below:

Finance of £15.4m will be required to enable the programme. It is assumed that this will be provided in the form of a loan from the DoH repayable over 20 years. There is a potential upside to the Trust’s Continuity of Services rating if non repayable Public Dividend Capital is negotiated successfully as an alternative. If no financing is available from these sources then there is an option to pursue a joint venture with a private sector partner.

2014/15 2015/16 2016/17 2017/18 2018/19 Total Capital Impact £, 000 £,000 £,000 £,000 £,000 £,000 Capital Costs 5,636 9,009 2,030 0 0 16,675 Capital Receipts 0 -1,833 -917 0 0 -2,750 Mortgage / Loan Repayment 0 1,500 0 0 0 1,500Net Capital Expenditure 5,636 8,676 1,113 0 0 15,425

Revenue Impact £,000 £,000 £,000 £,000 £,000 £,000Revenue Costs of Demolition 518 686 358 0 0 1,563New Depreciation Charge 207 523 596 596 596 2,517Capital Charges 199 496 548 527 506 2,276Savings -43 -1,112 -1,681 -1,859 -1,859 -6,554 Sum 882 594 -180 -737 -758 -198


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9.6.3 IT Strategy The IT strategy sets out the case for significant investment in IT as a key driver of clinical and financial benefits into the medium term. A range of options are presented from “do minimum” to “maximum investment = maximum benefits”. A summary of the costs of the strategy is set out below:

The capital and revenue costs of the recommended strategic options have been included in the plan. This is the most expensive option from an initial investment point of view. This is prudent at this time as it shows the Trust’s commitment to investing in IT but does not commit the Trust to

2014/15 2015/16 2016/17 2017/18 2018/19 Total Capital Costs £,000 £,000 £,000 £,000 £,000 £,000 Full EPR implementation charges 0 2,500 500 0 0 3,000 Hardware/infrastructure costs 0 0 200 200 200 600 Hardware/infrastructure costs + refresh 0 1,000 0 0 0 1,000 iPM merge 80 0 0 0 0 80 Supplier Hardware 156 0 0 0 0 156 Supplier Software 550 0 0 0 0 550 Supplier Implementation 180 0 0 0 0 180 Supplier Records Scanning 1,933 967 0 0 0 2,900 Data lines 152 0 0 0 0 152 Environment/Building work 369 82 82 82 82 696 Network equipment 95 0 0 0 0 95 VDI terminal 421 0 0 0 0 421 Licence costs 541 0 0 0 0 541 Storage costs 72 12 12 12 12 120 Consultancy Implementation costs 651 1,161 608 0 0 2,420 Trust Support (External Co buy in) 31 63 63 63 63 283 Trust Implementation (External Co buy in) 568 12 0 0 0 580 Total Capital 5,800 5,796 1,465 357 357 13,774

Revenue costs £,000 £,000 £,000 £,000 £,000 £,000 CSC iPM PAS extension 0 0 213 425 425 1,063 Extramed 202 130 99 0 0 431 Licence charge for full EPR 0 700 1,400 1,400 1,400 4,900 Ongoing system administration (Salford) 0 125 250 250 250 875 Supplier Maintenance & Support 63 127 127 127 127 571 Supplier Records Destruction 48 25 1 1 0 75 Supplier Records Transport 57 29 1 1 1 89 Data lines 232 143 143 143 143 804 Network equipment 19 19 19 19 19 95 Licence costs 108 108 108 108 108 541 SLA Costs 240 0 0 0 0 240 Hardware Support 19 19 19 19 19 94 Depreciation 725 1,450 1,633 1,677 1,722 7,206 Loan interest at 3.5% 235 348 346 300 253 1,482 Total 1,948 3,222 4,358 4,470 4,467 18,465


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implementing the specific options mentioned. The relevant business cases are being taken through due process to finalise this. The long term efficiency programme already assumes that the Trust will move to beyond upper quartile efficiency in the benefit areas identified in the IT investment strategy. The IT investment strategy is treated as enabling but not adding to the efficiency programme. The Trust is not able to finance the capital costs of these investments from existing resources so will require either a loan or non-repayable public dividend capital which may be available from bids to central monies or through negotiation as part of the “solvent restructuring” that the Trust may be subject to. For the purpose of the base plan a loan is assumed at an interest rate of 3.5% as this is projected to be the most likely financing method. This financing method has adverse incremental impact on the Trust’s “continuity of services” risk rating over the life of the plan. The downside risk scenario of the plan will consider the risk of not securing the necessary loans or public dividend capital. In the case of IT this would require the implementation of the relevant “do minimum” options. These options deal with service continuity issues but have fewer benefits in terms of enabling clinical and cost improvements. 9.7 Statement of Financial Position 9.7.1 Cash Reconciliation The five year planned statement of financial position is available at appendix H.2. The five year planned statement of cash flows is at appendix H.3. There are three key issues from the perspective of the SOFP.

It is assumed that the £26.3m Temporary Public Dividend Capital received to enable the Trust to continue to operate will be made permanent

A balanced operating cash flow will be achieved from 2014/15 onwards meaning no further

cash support from the DoH is required.

The Estate and IT Strategy will be financed by non-commercial loans The planned cash position over the five years of the plan is set out below:

2014/15 2015/16 2016/17 2017/18 2018/19£ 'm £ 'm £ 'm £ 'm £ 'm

Opening Cash 0.3 1.0 1.6 3.0 3.6I&E Surplus 1.6 3.1 4.6 5.1 5.5Depreciation 6.1 7.1 7.4 7.4 7.4Working Capital Improvement 0.5 0.0 0.0 0.0 0.0Capital Spend (17.5) (21.9) (10.9) (7.8) (7.8)Capital Receipt 0.0 1.8 0.9 0.0 0.0Repayment of loan re land(due to sale) 0.0 (1.5) 0.0 0.0 0.0Existing Loan Payment (1.4) (1.4) (1.1) (1.1) (1.1)New Loans 11.4 14.8 3.5 0.4 0.4New Loan repayment 0.0 (1.4) (3.0) (3.4) (3.5)Closing Cash 1.0 1.6 3.0 3.6 4.5


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9.7.2 Loans Reconciliation The loans anticipated over the life of the plan are set out below:

2014/15 2015/16 2016/17 2017/18 2018/19£ 'm £ 'm £ 'm £ 'm £ 'm

Opening MiB Loan -17.8 -16.7 -15.6 -14.5 -13.4New loan drawdownRepayment 1.1 1.1 1.1 1.1 1.1Closing MiB Loan -16.7 -15.6 -14.5 -13.4 -12.3

Opening Car Park Loan -2.1 -1.8 0.0 0.0 0.0New loan drawdownRepayment 0.3 1.8 0.0 0.0 0.0Closing Car Park Loan -1.8 0.0 0.0 0.0 0.0

Opening Estates Strategy Loan 0.0 -5.6 -14.3 -15.6 -14.8New loan drawdown -5.6 -9.0 -2.0Repayment 0.3 0.7 0.8 0.8Closing Estates Strategy Loan -5.6 -14.3 -15.6 -14.8 -14.0

Opening IT Strategy Loan 0.0 -5.8 -10.5 -9.7 -7.5New loan drawdown -5.8 -5.8 -1.5 -0.4 -0.4Repayment 1.1 2.3 2.6 2.7Closing Estates Strategy Loan -5.8 -10.5 -9.7 -7.5 -5.2

Opening Total Loans -19.9 -29.9 -40.4 -39.8 -35.7New loan drawdown -11.4 -14.8 -3.5 -0.4 -0.4Repayment 1.4 4.3 4.1 4.5 4.6Closing Total Loan -29.9 -40.4 -39.8 -35.7 -31.5


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9.8 Continuity of Services Rating 9.8.1 Summary of Continuity of Services Rating The Trust will return to surplus in the first year of the plan and will achieve a rating of two under the new continuity of services rating. The rate of progress beyond this point will depend on how the Estates and IT strategy are financed. The plan is based on the assumption of loan finance. This will depress the rating because of the amount of surplus being used up in loan repayments. A better position is achievable if the strategies are financed by public dividend capital as can be seen from the table below

2014/15 2015/16 2016/17 2017/18 2018/19

Ratings based on loanLiquidity rating 1 1 1 1 1Capital Servicing Capacity 2 3 4 4 4Overall rating 2 2 3 3 3

Ratings based on PDCLiquidity rating 1 2 3 3 4Capital Servicing Capacity 2 3 4 4 4Overall rating 2 3 4 4 4


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9.9 Downside Risk Analysis 9.9.1 Income and Expenditure – Downside Risk A range of income and expenditure downside risk scenarios have been modelled. The financial plan has sufficient resilience to deal with an average of 1.8% down side risk per year whilst maintaining an income and expenditure surplus. Risk / Mitigation

2014/15 2015/16 2016/17 2017/18 2018/191) Activity projections £,000 £,000 £,000 £,000 £,000

Risk - Activity 0.5% lower than plan -1,269 -2,516 -3,741 -4,953 -6,151Mitigation - Take out relevant costs 1,041 2,063 3,067 4,061 5,044Residual impact -228 -453 -673 -891 -1,107

2) Reconfiguration impact £,000 £,000 £,000 £,000 £,000Risk - loss of activity due to Healthier Together 0 -7,500 -11,250 -15,000 -15,000Mitigation - Take out relevant costs 0 6,150 9,225 12,300 12,300Residual impact 0 -1,350 -2,025 -2,700 -2,700

3) Income improvements £,000 £,000 £,000 £,000 £,000Risk - 50% contractual improvements not delivered -2,150 -2,150 -2,150 -2,150 -2,150Mitigation - no direct mitigation 0 0 0 0 0Residual impact -2,150 -2,150 -2,150 -2,150 -2,150

4) Cost improvements £,000 £,000 £,000 £,000 £,000Risk - 25% under delivery of cost improvements -4,049 -9,557 -13,891 -17,549 -21,182Mitigation - tactical controls 2,000 3,000 3,000 3,000 3,000Residual impact -2,049 -6,557 -10,891 -14,549 -18,182

5) Cost pressures £,000 £,000 £,000 £,000 £,000Risk - cost pressures 25% higher than forecast -1,950 -3,900 -5,850 -7,800 -9,750Mitigation - Bring forward CIPs 1,950 3,900 5,850 7,800 9,750Residual impact 0 0 0 0 0

6) Overall Impact £,000 £,000 £,000 £,000 £,000Residual impact -4,428 -10,510 -15,739 -20,290 -24,139Contingency Reserve 3,300 8,200 12,300 16,400 20,500Planned Surplus 1,600 3,100 4,600 5,100 5,500Residual surplus 472 790 1,161 1,210 1,861

Cumulative risk impact


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9.9.2 Down Side Risk - Cash Impact The cash impact of the downside income and expenditure risk has been modelled along with the impact of not getting loan or PDC finance to enable the estates and IT strategy. Key components of the cash management plan are a) further working capital improvements b) flexing the capital programme c) financing the critical elements of the estate strategy through a joint venture d) reverting to the do minimum option in respect of the IT strategy. The plan has sufficient resilience to continue to pay existing loan commitments and generate a positive cash balance over the life of the plan under the modelled downside scenarios. Risk / Mitigation

2014/15 2015/16 2016/17 2017/18 2018/19£,000 £,000 £,000 £,000 £,000

1) Loan repayments forecast -1,400 -1,400 -1,400 -1,400 -1,400Surplus available 472 317 371 49 651Working capital improvements 500 0 0 0 0Reduce capital programme 428 1,083 1,029 1,351 749Cash impact 0 0 0 0 0

£,000 £,000 £,000 £,000 £,0002) Estate loan / pdc not available -5,636 -9,009 -2,030 0 0

Reduce programme (Endoscopy / Learning Centre) 2,000 50 1,950 0 0Private finance re energy scheme 3,636 8,959 80 0 0Cash impact 0 0 0 0 0

£,000 £,000 £,000 £,000 £,0003) IT loan / pdc not available -5,800 -5,796 -1,465 0 0

Revert to do minimum option - capital 2,744 5,298 979 -129 -129Revert to do minimum option - revenue 28 890 1,095 957 957Delay capital programme 2,028 -992 -1,036 0 0Cash impact -1,000 -600 -427 828 828

4) Total cash impact -1,000 -600 -427 828 828

5) Revised Cash Forecast £,000 £,000 £,000 £,000 £,000Planned Cash 1,000 0 0 973 2,401Planned change in cash 0 600 1,400 600 900Cash Downside -1,000 -600 -427 828 828Revised Cash 0 0 973 2,401 4,129

In year risk impact

ORGANISATION RISK

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In this section: An outline of key corporate strategic risks and mitigations, in

relation to: - clinical care - operational delivery - governance - workforce - finance - the estate - informatics - service strategy

Key points: The strategic risks will form the core of the new Board

Assurance Framework.

ORGANISATION RISK

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10.1 Corporate Risk Profile – The Trust’s Most Significant Risks

RISK MITIGATING ACTIONS CLINICAL

Failure to respond to deteriorating patients

Further development of the ”level 1” and “Hospital at Night” workforce as part of new staffing structures

Continued work to improve handover processes

Regular monitoring and audit, including of the use of the Early Warning Score, recognition of sepsis, ventilation and cardiac arrest

Building on the benefits of much-expanded 7/7 consultant working in key specialties in the last three years

Action overseen and progress monitored via the Mortality Reduction Group

Failure to control infection

Continued implementation of the comprehensive C. Difficile Reduction Plan, within the Hospital, and with partners in the wider health community

Strengthened Microbiology function now in place

Regular observation and monitoring of hygiene standards and other safe practice takes place in all parts of the Trust

Control of infection practice and policy reinforced at all levels, and regularly reviewed by the Board

OPERATIONAL Failure to sustain national

waiting time standards

Implementation of the Bolton-wide Urgent/Emergency Care Plan

Daily performance monitoring and capacity planning in place

Operational plans in place to achieve separation of elective and non-elective capacity as much as possible

GOVERNANCE Failure to address the

regulator’s “red” governance rating and the Trust’s breach of its Provider Licence

Continued implementation of the Governance Action Plan, incorporating the recommendations of recent external expert reviews

Planned review and redesign the Trust’s Risk Management processes

Action in hand to complete consolidation of Executive Team – permanent and stable team to be in place by March 2014

ORGANISATION RISK

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WORKFORCE Failure to reduce sickness

absence

Continual reinforcement of compliance with policy, and close performance monitoring

Plans to harmonise Trust sickness absence policies (post-hospital/community services integration)

Implement measures to improve staff uptake of flu vaccination

Ensure the provision of responsive and supportive workplace health and wellbeing services

Risk to sustaining good employee relations through organisational change

Staff Side representatives to be fully briefed and engaged in planning and delivery of workforce changes

Strengthen staff communication, including Trust-wide engagement events and Chief Executive briefings

FINANCE Failure to achieve planned

Income and Expenditure surplus

See ‘Downside’ – Section 9.9

ESTATE Failure to provide an efficient

estate, fit for purpose, thereby restricting the implementation of service plans

Implementation of the agreed Estates Strategy, supporting the strategic service priorities of the organisation (See Section 8.1)

INFORMATICS Risk of loss of patient or staff-

identifiable data, leading to personal, financial and reputational damage

Measures in place to improve coverage of staff training in Information Governance policy and practice

Regular audit of systems and practice in place The Trust’s strategy is to reduce paper by

implementing systems that enable access to sensitive personal data predominantly via secure electronic records (See Section 8.2)

Risk that strategic development will be hampered by poor IT infrastructure

Implementation of the agreed Informatics strategy, supporting the strategic service priorities of the organisation (See Section 8.2)

SERVICE STRATEGY Risk that the outcome of the

“Healthier Together” exercise will significantly downgrade the RBH scope of service,

The delivery of high clinical standards of and operational performance is fundamental to Trust plans

Achievement of the financial plan is recognised

ORGANISATION RISK

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threatening financial and clinical viability

in this strategy as the enabler for all other service plans

Clinicians and other staff will be supported to make the case clearly for the service strategy set out in this document, in clinical and other planning forums in Greater Manchester, and in the anticipated consultation process

Continue to work with other providers in the North West Sector of Manchester

Arrangements are already in place to work closely with commissioners to secure the changes needed in the local model of care, particularly for older people

Risk that integrated care in Bolton is not achieved, leading to escalating demand on hospital services

There will be full engagement with partners in primary and social care, in the planning and delivery of the vision for integrated care in Bolton

Develop workforce capacity and capability to ensure that the Trust realises the full benefits of integrated services within the organisation

10.2 “Downside” Projections

A range of income and expenditure downside risk scenarios have been modelled.

The financial plan has sufficient resilience to deal with an average of 1.8% down side risk per year whilst maintaining an income and expenditure surplus. See section 9.9

ORGANISATIONAL DELIVERY

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In this section:

A description of the main components of the Trust’s governance systems and structures, including the operation of the Board and Council of Governors, risk management processes, organisational and leadership development, partnership working, performance management and accountability and programme management

Key points: The Trust has already strengthened all aspects of corporate

governance in response to performance failures occurring in 2011/12.

Further external expert review and benchmarking has provided the basis of a continuing improvement plan, owned and monitored by the Trust Board.

Improvements include a renewed focus on risk management and improved integrated performance monitoring and management.

The Trust’s new governance and management structures are now in place and significant progress has been made against its comprehensive governance improvement plan. The organisation now has the benefit of a more stable leadership team. Remaining key appointments are expected to be in place by the end of this financial year.


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11. ORGANISATIONAL DELIVERY

11.1 Governance

11.1.1 Board and Board Development

The Trust is currently in breach of its Provider Licence and has an agreed series

of actions to address Monitor’s discretionary requirements and enforcement undertakings. Since being placed in breach of the Terms of Authorisation in April 2012 there have been significant changes at Board level. Less than half of the Board members in post at that time are still in post in September 2013 and further new appointments to the roles of Chief Operating Officer and Director of Workforce and Organisational Development are in hand. Prior to being placed in significant breach the Board had recognised the need to address its governance weaknesses and had commissioned a review from KPMG. The report included 60 recommendations; three-quarters of these recommendations have now been addressed with actions in hand to address the remaining issues, which primarily relate to Risk Management and Board Development. The Trust has commissioned the Good Governance Institute to support the programme of work required to strengthen Risk Management and to develop the new Board. This programme of work includes support to strengthen the Board Assurance Framework and an overall review of risk management processes to ensure a clear line of sight from Ward to Board.

11.1.2 Governor Development

The Council of Governors was established prior to authorisation as an FT in May 2008, and ran in shadow form until authorisation in October of that year. There are currently 40 seats on the Council of Governors, 38 of which are currently filled. The rolling programme of elections adopted in the initial constitution has been effective in ensuring a gradual turnover of Governors with 13 of the original Council of Governors still in post.

A Governor training programme is in place to meet the requirements of the 2012 Act. This includes a local induction programme followed by a rolling programme of bi-monthly training sessions which all governors are required to attend. To complement this, a series of joint training sessions with neighbouring trusts has been arranged and Governors are encouraged to attend regional events run by the local Trust Secretary Network and by the Foundation Trust Network.

An annual review of the Council of Governors is conducted to test the effectiveness of training and to ensure future training is tailored to the needs of the collective body and the individual.


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11.1.3 Risk management

The Trust has recognised the need to strengthen risk management and has now

started work with the Good Governance Institute to address the recommendations identified by KPMG and Deloitte. Updated Risk Management Policy and Structures will be in place by the end of October.

11.1.4 Internal Audit Plan

In June 2013 the Trust appointed PWC as internal auditors. The Internal Audit plan will be focused on those areas identified as requiring additional assurance –the plan is attached at Appendix F.

11.1.5 Governance Structures

The Trust’s Governance Structures are set out below:

Board of Directors

Remuneration and nominations Committee

Charitable Funds Committee

Finance and Investment Committee

Audit CommitteeInternal AuditExternal Audit

Clinical Audit

Updated April 2013

Council of Governors

Quality Assurance Committee

Infection ControlMortality ReductionResuscitationThrombosisNutrition AdvisoryMedicines Management/D&TCCritical CareEnd of LifeSafeguarding

Clinical Governance and

Quality Committee

Patient Experience Inclusion & Partnership

Committee

Divisional Quality Board/Forum

Health and Safety

Committee

Executive Board

Directorates and Divisions

Estates CommitteeInformaticsCommittee

Workforce Committee

New Structure September 2013

CRIG

Risk Management Committee

11.2 Organisational Effectiveness and Leadership

The Trust sees a clear link between the achievement of the highest levels of quality and safety and effective people management. It has developed an award-winning approach to embedding an engagement culture, that has been in place since 2010. The approach is central to achieving the aim of having the best place in which to receive care and treatment and as a great place to work.


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The components which will enable this are:

A set of core values that have been embedded into organisational life (i.e. appraisal, recruitment, investigative processes and subsequent organisational learning) in order to set out and performance manage behavioural and attitudinal expectations.

An Early Warning Matrix that acts as a cultural barometer in identifying

correlations between behaviour, performance, productivity and patient outcomes.

An established mechanism for measuring staff engagement levels on a quarterly

basis. A comprehensive range of Human Resources/Organisational Development

mechanisms, processes and policies to detect and support performance improvement at individual, team and organisational levels.

Leadership and management capability is critical to achieving a continuously improving

performance culture. The challenge for our managers and leaders is to have the necessary knowledge, skills and behaviours to inspire and motivate the workforce. A range of comprehensive assessment tools, development and support programmes are available.

These are the elements of the Trust’s leadership development approach:

Establishing a high performance and accountability ethos, aligned with a culture of engagement.

The introduction of a Management Effectiveness Pathway which sets out the

direction of travel for all our managers and medical leaders to maximise both their development and continuous learning to achieve organisational goals.

Key elements within the intensive programme of leadership and management

development include pre-programme measurements against clinical and workforce performance metrics, with post-programme review of effectiveness in achieving improvements.

The use of a Development Centre approach for managers to assess capability to

deliver objectives and priorities, and to enable the Trust to identify and nurture talented staff.

Ongoing coaching and support to managers to improve and maintain

performance levels and to identify potential threats to and opportunities for future performance.


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11.3 Partnerships

Achieving the Trust’s goals, for its patients and for the organisation, will depend on active

and effective partnership with other organisations and individuals. Its governance arrangements support full input by clinicians and managers to a range of essential external relationships, in particular:

Bolton-wide health and social care planning and delivery, under the auspices of

the Health and Wellbeing Board and Bolton’s Vision Partnership.

The Bolton Clinical Commissioning Group and its joint clinical planning forums.

Healthwatch – Bolton

Greater Manchester-wide planning groups

Greater Manchester Cancer Provider Board

Emerging Strategic Clinical Networks

Joint planning group with Wrightington, Wigan and Leigh FT

Staff Side and professional organisations

The Care Quality Commission and other regulators

Universities and the local Deanery

11.4 Managing Performance

11.4.1 Organisational Structures and Accountability

The restructure of Divisional Management arrangements in 2012/13 was designed to ensure that line management and accountability for performance were strengthened at all levels.

The performance management approach, now embedded in the Trust, is based on six building blocks:

Individual accountability set out in job roles

Regular objective-setting and appraisal

Annual Corporate/Divisional Performance agreements

Maximum devolution of control over contract income and expenditure aligned to Divisional accountability for performance

Service line management as the principal means of financial control, from 2014/15 onwards.

Use of a comprehensive Performance Assessment Framework (PAF) and


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regular face-to-face review with Divisional Teams to account for progress, deviation from plan and corrective action.

11.4.2 Measuring and Tracking Performance

The Trust’s Performance Assessment Framework (PAF) brings together key

indicators of performance, including on the delivery of contract commitments, efficiency, workforce and operational delivery. The PAF is continually developing to reflect corporate priorities. The Trust is now at the point of piloting a corporate integrated dashboard of indicators, which will provide greater clarity on performance at Board level, and which will equally be capable of supporting a view of performance at each level in the organisation. A copy of the dashboard is attached at Appendix G.

11.5 Programme and Project Management

A Corporate Programme Management Office (PMO) has been established within the

Directorate of Finance. The PMO Team have both project management and improvement skills with the capability to support major projects across the Trust.

The leadership of and accountability for projects is embedded in the role of senior Directorate and Divisional managers. Project management is recognised as a key skill in the Trust’s Training and Development priorities. The priorities of the corporate PMO are determined annually in the light of corporate objectives.

APPENDICES

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APPENDICES

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A Bolton Integrated Care Plan

B Quality Strategy

C Estates Strategy

D Informatics Strategy

E Workforce Strategy

F Internal Audit Plan 2013/14

G Performance Framework - Dashboard

H Financial appendices

H.1 Planned Statement of Comprehensive Income H.2 Planned Statement of Financial Position H.3 Planned Statement of Cash Flows H.4 Planned Continuity of Services Rating (Loan Finance) H.5 Planned Continuity of Services Rating (PDC Finance) H.6 Planned Statement of Comprehensive Income - Bridge H.7 Planned Income - Bridge H.8 Planned Statement of Comprehensive Income - Monthly Phasing H.9 Planned Income and Cost Improvements H.10 Planned Capital Spend H.11 Estates Strategy Summary H.12 IT Strategy Summary

APPENDICES

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H.13a Cash reconciliation - Loan finance H.13b Cash reconciliation - PDC finance H.14 Loans reconciliation H.15 Summary Activity Forecast H.16 Detailed Activity Forecast H.17 Bed Base Impact H.18 Workforce Plan - Summary H.19 Workforce Plan - Bridge H.20 Downside Risk - Income and Expenditure H.21 Downside Risk - Cash H.22 Healthier Together Estimates H.23 Income Upsides H.24 LongTerm Efficiency Plan H.25 Community Services Long Term Financial Plan H.26 Letter from Bolton CCG

Financial Appendices H1-H23.xlsx

GLOSSARY OF ABBREVIATIONS

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A&E Accident and Emergency AQP Any Qualified Provider (Commissioner qualification process aimed at establishing a list of

providers eligible to provide a service) BFT Bolton NHS Foundation Trust CAMHS Child and Adolescent Mental Health Services CATS Clinical Assessment and Treatment Services CCG Clinical Commissioning Group CCU Coronary Care Unit CEO Chief Executive Officer CIP Cost Improvement Programme CNST Clinical Negligence Scheme for Trusts COO Chief Operating Officer CQUINS Commissioning for Quality and Innovation - payment framework CSU Commissioning Support Unit CVD Cardiovascular Disease DC Day Case DGH District General Hospital DNA Did Not Attend DoF Director of Finance DoH Department of Health EBiTDA Earnings Before Interest, Taxation, Depreciation and Amortisation EDMS Electronic Document Management System ENT Ear, Nose and Throat EPR Electronic Patient Record FFCE First Finished Consultant Episode (an inpatient admission or day case) FT Foundation Trust G-I Gastro-intestinal GM Greater Manchester GP General Practitioner HC Health Centre HDU High Dependency Unit Healthier Together

Greater Manchester review of configuration of healthcare services

HealthWatch Local patient and public representation organisation HR Human Resources I&E Income and Expenditure ICU Intensive Care Unit IOG Improving Outcomes Guidance (standards for cancer care) IP Inpatient IT Information Technology KPI Key Performance Indicator KPMG Consultancy/Accountancy provider MiB Making it Better (Greater Manchester Women’s and Children’s Services reconfiguration) MSK Musculoskeletal OD Organisational Development OJEU Official Journal of the European Union ONS Office of National Statistics OOH Out of Hours PAF Performance Assessment Framework PAMU Princess Anne Maternity Unit PBR Payment by Results

GLOSSARY OF ABBREVIATIONS

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PCT Primary Care Trust (until 2013, the commissioning body for services for a local population) PDC Public Dividend Capital PEST Political, Economic, Social, Technological – analysis of external forces on an organisation PMO Programme Management Office PWC Price Waterhouse Coopers QIPP Quality, Innovation, Productivity and Prevention SRFT Salford Royal Foundation Trust SWOT Strengths, Weaknesses, Opportunities, Threats – analysis of an organisation’s position TCS Transforming Community Services (policy for the location of former PCT-managed

community services with other provider structures) WTE Whole Time Equivalent WWL Wrightington, Wigan and Leigh NHS Trust

Report to: Health and Wellbeing Board Date: 3 July 2013 Report of: Report

No:

Contact Officer: Wendy Meredith

Director of Public Health Tele No: 33 (7859)

Report Title: Health and Social Care Integration Non Confidential: This report does not contain information which warrants its

consideration in the absence of the press or members of the public.

Purpose: The report details the delivery of integrated health and social care

services which deliver better quality and outcomes for patients.

Recommendations: The board is requested to consider the report and support the

direction of travel.

Decision: Background Doc(s):

2

June 1, 2013 [VISION AND MODEL FOR HEALTH AND SOCIAL CARE IN BOLTON]

Introduction services which deliver better quality and outcomes for patients. These services will be effective in meeting the twin challenges of increasing demand and dwindling resources whilst at the same time delivering better outcomes for patients. The new model of care is described from the perspective of Mrs Bolton. Mrs Bolton is not a real person but her experiences are typical of some of the problems which patients tell us they experience. The emerging Bolton model of service is centred round the needs of Mrs Bolton and aims to her well and in her own home recognising the importance of family and community in promoting wellbeing. Context As the population of Bolton grows older, the health and social care system in the Borough is under increasing pressure from a combination of reduced resources and increasing demand for services. It is becoming increasingly clear that current models of service provision are rapidly becoming unsustainable. Within Bolton, there is a strong track record of partnership working between Bolton Clinical Commissioning Group (and previously NHS Bolton), Royal Bolton Hospitals Foundation Trust, Greater Manchester West Mental Health Trust and Bolton Council. Primary care services in Bolton are an asset and have the potential to form the building blocks from which a truly integrated system can be developed. General Practitioners and their teams are both providers and commissioners of health care. In Bolton, General Practices have a track record in implementing population health programmes delivered at pace and scale such as the Big Bolton Health Check. Principles to guide health and social care integration The following principles have emerged from discussions between partners involved

-being Board: 1. Patients should receive high quality care which is centred on their needs

rather than the needs of professionals and organisations. 2. The clients/patient should be empowered to manage their own care and self-

care 3. Services should be local wherever possible 4. Services should be centralised where necessary (to ensure clinical safety) 5. Care should be integrated across health and social care in all settings 6. Services should be accessible, convenient and responsive 7. Information and communications should be centred around the client/patient

not the organisation/professional 8. High quality care should be accessible quickly regardless of the time or day of

the week

Mrs Bolton is a 78 year old lady who lives alone. Her granddaughter lives 60 miles away in Leeds with her husband and 3 children under the age of 10 years. Her daughter lives in Bournemouth. Mrs Bolton's husband died 2 years ago.

3

Mrs Bolton has moderate Chronic Obstructive Pulmonary Disease from her work in the mill and becomes breathless when climbing stairs. She walks with a stick, when she remembers it. She has high blood pressure and swollen ankles. Her daughter is concerned her mother is displaying increasing signs of forgetfulness. Mrs Bolton does not go out on her own since her fall earlier in the year. Her friends visit once a week and bring her shopping. Over the past 12 months Mrs Bolton has had 3 hospital admissions. She was admitted to treat a chest infection but stayed for 21 days as she contracted Norovirus whilst in hospital. Shortly after her return home, she fell and was taken to A&E but stayed in for less than 24 hours. She had a horrible time in A&E because she fell in her bathroom at 2am on a Sunday

hospital for cellulitis.

to

where to turn if she needs information. She sometimes has to wait a long time for some of ows all the staff

are very busy. She was telling her granddaughter that in the last few weeks she has seen her GP, Practise Nurse, District Nurse, IV Therapy Nurse, Social worker, Carers (Bolton Council), Physiotherapist, Occupational Therapist (NHS), Occupational Therapist (Bolton Council), Respiratory consultant, Memory Assessment Clinic. Vision for integrated services

Mrs Bolton will have a single key worker who coordinates her care. She will have a single phone number she can phone at any time. She will agree a care plan with her key worker and she will keep it so when she sees

the different people who help her, they can see what thher who she shares it with.

Her key worker will arrange for other people to come in and help her when she needs them such as the physiotherapist which helps her breathing.

She fells more confident and has the information, skills and resources she need to manage her own health and health conditions and is supported to monitor her own health.

She also has more opportunities to get involved in community groups and other local activities

What does this mean for services?

General Practice will: Organise the systematic and proactive management of patients with chronic

diseases to improve health outcomes, reduce the need for admission to hospital. Use practice information systems to systematically identify all patients at risk of

hospital admission and ensure that their medical and social needs are proactively managed.

4

Ensure that care will be dignified care. Undignified care is that which renders individuals invisible, depersonalises and objectifies people, is abusive or humiliating, narrowly focussed and disempowers the individual.

-of self-care and alternative provision such as pharmacy.

Integrated care teams will: Be formed from primary care, social work and community health service providers

working at the community level to ensure integrated care management. Social as well as medical concerns will be proactively addressed (debt, poor housing, isolation)

Continue to manage patients during admission to hospital in partnership with the secondary care team. Discharge planning will begin prior to admission. The numbers of unplanned admissions to hospital will reduce.

Community services such as district nursing, physiotherapy and podiatry are an essential part of an integrated and well-targeted system of care. Community health services are integrated with general practice and social work teams to support clients/patients to remain independent and safe for as long as appropriate.

When patients do need urgent/unplanned care, there is a crisis team available (24/7)

hospital team to ensure early discharge and provide post-discharge care. Provide care every day of the week. Ensure that care management delivered by the integrated community team continues

during any hospital stays supported by better use of information technologies. Ensure that care is dignified care. Undignified care is that which renders individuals

invisible, depersonalises and objectifies people, is abusive or humiliating, narrowly focussed and disempowers the individual.

Social work will: Social care has the best chance of keeping older people out of hospital and has the best chance of getting them home safer, quicker. Work is on-going to describe this in more detail.

Specialised (secondary care) services will: Will coordinate their work with integrated community teams to ensure specialist

expertise is available, particularly in areas such as dementia care, geriatrics, diabetology, respiratory care.

Work is on-going to describe the model of secondary care.

Health and social care commissioners will: Commission integrated health and social care with common service specifications,

contracts and funding mechanisms. Develop and implement investment models which enable new ways of working. Work in partnership with providers develop and implement new models of care.

5

The Bolton Model The Bolton model for integrated health and social care will be designed around the needs of populations of 20,000 to 30,000 people built from clusters of practices. This will result in 10

a tool currently being tested and refined in the Great Lever pilot. A multi-disciplinary health and social care team will serve each population cluster. Patients/clients with multiple long term conditions and/or at high risk of hospital admission and the frail elderly will be designated a care coordinator who

multi-disciplinary team will include adult community nurses, GPs, social workers, physiotherapists, occupational therapists and community psychiatric nurses and generic workers. The multi-disciplinary team will also systematically identify individuals at high risk of future health and social care need and provide advice, support and assistance to enable people to remain healthy happy and independent for longer. The Staying Well approach is being piloted in 6 practices and early evaluation is very positive. The multi- services available 7 days a week, 365 days a year. The multidisciplinary team will be able to pull in specialist expertise from the following tissue viability; palliative care; IV therapies, microbiology, diabetology; cardiology, gastroenterology, dermatology, rheumatology, gynaecology, respiratory medicine, orthopaedics, speech and language therapy, dietetics and podiatry. Rehabilitation (Cardiac, Pulmonary and Heart Failure). Falls and re-ablement services will also support the multidisciplinary teams. Geriatric medicine and Psychiatry will be particularly important. Consultant job plans will reflect these new ways of working. Working Group

Bene, Dr Barry Silvert, Jackie Bell, Isobel Southern and Wendy Meredith.

6

Integrated Health and Social Care Plan Summary - Bolton Council

1. Overall Aim To deliver integrated health and social care services for the people of Bolton which:

Are centred around the needs of the patient and aim to keep patients well , independent and in their own homes recognising the importance of family and community in promoting wellbeing.

Provide a good experience of care for patients and their families and result in better outcomes and care closer to home.

Meet the challenges of rising need for services and dwindling resources.

2. Partners involved and Governance In Bolton, we have a strong track record of partnership working between the partners involved: Bolton Clinical Commissioning Group (and previously NHS Bolton); Royal Bolton Hospitals Foundation Trust; Greater Manchester West Mental Health Trust and Bolton Council. The development of integrated health and social care is sponsored by the Health and Wellbeing Board and is a clear priority in

Health and Wellbeing Board has established a Joint Transformation Group with We are also working with

Healthwatch and the Community and Voluntary Sector to ensure that we engage patients fully in our plans. The governance structure is set out in the diagram below with reporting into the Health and Wellbeing Board and each partner organisations governing body. Figure 1: Governance Structure

We have a set of task and finish groups reporting into each of the project teams.

3. People/Patients

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People with multiple long term conditions including mental health problems, people at risk of hospital admission and the frail elderly will be identified systematically and offered proactive support to manage their health conditions. We have piloted this approach in the Great Lever area of the Borough and have refined our risk stratification approach in response to the evaluation of the Great Lever project.

need for health and social care services in the over 50 age group using practice registers to risk stratify the population and offer early intervention to reduce future need/demand for care services. The diagram below shows how the service responses relate to the overall need. Figure 2: Levels of intervention according to risk stratification

4. The New Service Model In Bolton, we are currently refining our outline model for integrated care based on the proof of concept work we have undertaken in the Great Lever and Staying Well pilots. The outline model is set out in the diagram below. Figure 3: integrated Care Model

8

A multi-disciplinary health and social care team will serve a population cluster of approximately 21,000 to 30,000 people formed from groups of general practices. We will have 10 clusters in the Borough. Patients with multiple long term conditions including mental health problems, and/or at high risk of hospital admission and the frail elderly will be designated a care

care plan. The multi-disciplinary team will include adult community nurses, social workers, physiotherapists, occupational therapists, community psychiatric nurses, general practitioners and generic workers. The over 50 population will be risk stratified by the index of potential care need and people at high risk of future health or social

See diagram below. Figure 4: Staying Well pilot

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Patients/clients will be supported by community assets which enable them to remain independent with greater confidence to manage their own care. The multi-disciplinary team will operate hen patients do need urgent/unplanned care, there is a crisis team available (24/7) to

rk with the hospital team to ensure early discharge and provide post-discharge care. See diagram below. Some of the secondary care specialties provided by Royal Bolton Hospitals Trust and Greater Manchester West Mental Health Trust, for example geriatric medicine, will provide specialist support into the multi-disciplinary team. Figure 5: Integrated Care system

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5. The Investment proposition

The number of people over 65 in Bolton is projected to grow from 46,000 in 2013 to 51,900 in 2020 and all partners are required to make significant cost reductions. Furthermore, the economic risks and benefits are not shared by all partners. Integrated care solutions are more cost effective than current models and should result in reduced admissions to hospitals and care homes, removal of duplications and fragmentation and reduced future demand. These potential financial benefits are offset by the cost of new delivery models, the growth in population and associated demand and individual organisations savings plans. Moving to integrated care will cost money before it generates savings. Work to quantify the current spends on care for older people and other groups with high risk of hospital admission, is underway. New contractual and financial arrangements will be required which support integrated commissioning arrangements with common service specifications, contracts and funding mechanisms. The development of investment models which enable new ways of working are in development.

6. Evaluation The evaluation framework is being developed by engaging with older people and local voluntary groups. A set of key outcome metrics is being worked up which start

metrics are under consideration: % reduction in emergency admissions for Bolton residents; % reduction in readmissions to hospital for Bolton residents, % reduction in permanent admissions to residential and nursing care; increased % people dying in place of their choice; increased % people self-reporting improved quality of life.

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7. Key milestones Agree partners involved and governance Agree vision and model Model future need/demand Agree risk stratification model

Refine model based on patient and carer engagement Develop investment model Agree evaluation criteria Agree and test clustering model Develop community resilience and self care plan Evaluate staying well pilot Develop information-sharing agreements Review and redesign workforce

APPENDIX B

FOREWORD

? INTRODUCTION FROM CHAIR AND CHIEF EXECUTIVE

This presents a great opportunity to emphasize the values early on in relation to attitude and behaviour in relation to the patient’s experience. Engagement is an integral ‘golden thread’ throughout this alongside Estate and Information. Bolton FT Definition of quality – to be agreed/suggested by staff as part of the communication strategy

CARING, SAFE, EFFECTIVE Our Aims for the Quality of Care in Our Organisation We aim to rise to the challenge of delivering safe, effective and compassionate care. To do this we must maintain and strengthen the focus on quality in the face of financial and organisational challenges. We must respond to the call from Francis, Keogh, Cavendish and Berwick to listen to and act upon the concerns of our patients, their carers, their families and our staff. We will achieve this by putting patients at the heart of how we do things, actively seeking and demonstrating learning from their feedback We will work on a portfolio of projects that will lead to demonstrable improvements in outcomes, safety and patient experience. Each project workstream will involve patients and staff from across the organisation, working systematically, sharing best practice and using proven quality improvement tools to ensure consistent delivery of improved performance. Key Ambitions

Over the last five years our mortality rates have fallen year-on-year. The work of the Mortality Reduction Group will continue with the goal of no needless deaths in this organisation.

Reduce mortality

Key target - Bolton to be in the top 10 NHS Hospitals as measured by risk adjusted mortality comparisons.

We will focus on a range of infections including Clostridium Difficile (C.Difficile), hospital acquired pneumonia and surgical site infection. We will be vigilant in monitoring, and learning from critical analysis of cases, and using evidence-based prevention measures.

Reduce harm

Key target - Deliver 50% year-on-year reduction in hospital acquired infections, including C.Difficile

We will regularly produce and review relevant outcome measures for our clinical services. This information will be compared with other organisations and used to drive continuous improvement.

Improve outcomes

Key target - Share benchmarked clinical outcome data in a transparent fashion with patients

Improve patient experience

Providing a good quality patient experience requires actively seeking, responding to and learning from patient feedback. We will provide opportunities for feedback for all patients and carers.

Key target - Develop a patient and public-designed system for responding to and learning from complaints and patient feedback.

We will build on current strong foundations of good quality care and improvement methodology. We will deliver quality improvement by working with and empowering patients and staff across the organisation. Quality improvement is seen as essential to the financial sustainability of the Trust. We believe that high quality care need not cost more. Getting it right first time, and moving care out of hospital when appropriate is less costly and the right thing to do for patients. Cost improvement programmes will only be implemented after a full quality impact assessment.

OUR VISION, VALUES AND AIMS

ORGANISATIONAL CULTURE

An organisation’s culture is derived from the behaviours and attitude of the workforce and leadership. A consistent theme that has emerged from our Big Conversation staff engagement events, is the deep motivation of staff to do their best for the people who need their care. The personal and professional commitment of the workforce are reflected in our organisational values. We will continue to embed the Core Values of our Trust into all aspects of organisational life, as the foundation for the delivery high quality care The Trust will also continue to build capacity and capability in our workforce to ensure that our staff have the skills to deliver high quality care, aiming for zero harm to patients, and looking for opportunities, everyday, to improve what we do Enabling the delivery of highest quality care is at the heart of all our leadership programmes, including those for clinical and medical leaders. All our programmes evaluate the development of leadership skills throughout, tracking productivity and quality improvements made by each participant. Continuing to build and develop our coaching culture will also provide additional support to help individuals and teams to realise their potential, working with staff to enable them directly to influence how things are improved in their areas of work.

DELIVERING THE STRATEGY Delivery of our strategy will be through programme management of a series of workstreams, designed to underpin our fundamental aim - to provide caring, safe and effective services. The workstreams have been identified following wide consultation with clinical and managerial staff and governors. They comprise four quality improvement workstreams targeting specific areas of improvement in clinical outcomes, patient safety and patient experience. They are underpinned by three enabling workstreams. Each workstream builds on existing work, but adds focus and stronger performance management to ensure delivery. Each workstream will have a clinical leader, supported by a multidisciplinary team and with a wide range of capability and experience drawn from across the organisation. Key members of each team will be patients and members of the public. Each workstream will use a systematic approach and proven quality improvement tools, including valuestream analysis, strategy and policy deployment, visual management and Plan-Do-Study-Adjust (PDSA) cycles, to build continuous improvement. Teams will scope their work at initial workshops, using external experts where necessary; produce a clear description of their purpose and their plans; hold learning sessions and summits; and scale-up and spread their learning. They will identify their priorities, the resources required, set out ambitious annual goals, and define and track the relevant measures of progress. Our Goals Reducing Mortality – Our Goals

Bolton to be within the top 10 NHS Hospitals for risk adjusted mortality Bolton to be a leading unit for low perinatal mortality

Preventing Infection and Harm – Our Goals

Strengthen the infection control culture, with infection control champions in all clinical areas Deliver 50% year-on-year reduction in C. Difficile rates Deliver target reduction in other forms of healthcare acquired infection Ensure compliance with antibiotic policy across the Bolton healthcare community No “Never Events” (specific types of healthcare-related harm, or potential harm, that are

judged to be “zero tolerance”) Achieve levels of quality care that ensure maximum reward from CQUINS funding, and year-on-

year improvement in Harm Free Care performance (relating to catheter care, prevention of falls, prevention of pressure ulcers ,and assessing patients for the risk of blood clotting)

Responding to and Learning from Harm and Errors – Our Goals

Ensure that the Trust’s complaints process is fit for purpose Encourage the reporting of clinical incidents Develop an innovative system for sharing learning from harm and errors Ensure there is a strong patient and public voice in all aspects of learning from harm and errors

Enhancing Patient Experience – Our Goals

Develop a matrix of patient experience scores across the organisation to give a clearer picture of variation in the way that patients experience our services

Share best practice and develop action plans to address our weaker areas Continue to improve the coverage of the Friends and Family test and use the results to shape

our improvements – aiming for the best scores in the country from our patients

Essential Enabling Workstreams Informatics, IT and Information Driving Better Care

Develop performance reports that flow from ward to Board level Deliver IT strategy to facilitate safe, effective care Improve IT access across the organisation Building our presence on the web to ensure that patients can access performance data and

advice Staff Engagement and Training

Develop an organisational culture of patient focus and quality improvement Ensure 100% compliance with mandatory training that includes quality improvement

techniques Introduce learning passports Recruit staff who are caring and compassionate Develop a no-blame culture Establish multiprofessional quality forums in each speciality to engage all levels of staff

Estates and Facilities

Ensure that patient areas allow privacy and dignity Ensure easy patient access Ensure the design and maintenance of our estate and facilities support safe care

MEASUREMENT To judge progress against the goals we have set ourselves in this strategy we will monitor a range of relevant indicators. These will be incorporated into an integrated report, so that they can also be seen in the light of other aspects of organisational performance (such as workforce, operational delivery and finance). The measures which are relevant to tracking improvements in the quality of care, include:

High-level indicators which relate to the Trust’s key priorities for clinical quality. These will be set on an annual basis and will form the basis of the Trust’s Quality Account.

Commissioning for Quality and Innovation (CQUINs) targets – these targets include national, regional and local CQUINs which are agreed with commissioners on an annual basis, as part of our service contracting negotiations. Achievement of relevant standards results in the payment of quality incentive monies.

“Advancing Quality” – these are groups of indicators related to compliance with best practice (also called “care bundles”), relevant to the management of specific conditions

Quality Schedule measures – these are other measures of quality, agreed with our commissioners as part of the Trust’s contractual commitments

Trust clinical quality indicators – other Trust-specific indicators that are established at Trust, Division and service level as part of our internal planning and performance systems

Early Warning Matrix – a report bringing together a group of location-specific indicators on workforce and the quality of care, which may identify potential “hot spots” for further action.

The Trust will also use a wide range of other evidence, observations, user-feedback, audits and external assessments, to assess the quality of its services.

Governance All workstreams will be overseen by the Trust’s Quality Improvement Team. This will be jointly chaired by the Medical Director and Director of Nursing. The seven workstream leads and a patient representative from HealthWatch will support them. The team will provide leadership, articulate goals, ensure that the work is communicated widely and establish and performance manage the full programme of work. The Quality Improvement Team will report to Trust Board via the Quality Assurance Committee. Communication Plan To be developed. Why we know we can do it Strong performance, including resilience shown by staff during a period of turnaround Strong improvement track record Strong clinical staff across a wide range of services “It is a long-term project – let’s start building”

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APPENDIX C

Developing an Estate Strategy

Making the Estate Work for the Future

Bolton NHS Foundation Trust

2013 to 2018

Discussion Stage

2

1. Introduction

The main objective of the Estate Strategy is to support the Clinical Services Strategy, providing accommodation that fully supports patient care in premises that are well maintained, safe and operated economically. Bolton NHS Foundation Trust operates within premises that it owns on the Royal Bolton Hospital site and at Bolton Diabetes Centre. The Land and Building assets that the organisation owns are currently valued at £110.8m. The Trust also operates within community premises under licence arrangements with NHS Property Services. The recent integration of community services provides the organisation with a complex portfolio of premises. The physical condition and functional suitability of the premises from which the organisation operates varies immensely, from the new Bolton One and Breightmet Health Centre buildings, which were recently procured under the Local Improvement Finance Trust (LIFT), to older Victorian properties that have inherent backlog maintenance issues. There is now a need to develop a new Estate Strategy that moves away from a reactive approach to clinical service needs, and moves towards performance management of building assets during their normal life cycle in terms of risk, quality, functional suitability, effectiveness and efficiency, ensuring value for money in all required future investment into the Estate. Early this year work started on integrating a new Estate Strategy with the Clinical Service Strategy, ensuring that organisational premises support the future clinical service needs, whilst also identifying surplus buildings and land assets that could be released. This paper provides an opportunity for members to discuss the emerging Estate Strategy and also provides a number of recommendations for consideration.

2. Clinical Service Strategy The Trust Estate Strategy must support the Clinical Service Strategy ensuring a realistic response to four fundamental factors:

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The over-riding imperative to provide services that are high quality, safe, effective and which provide a good experience for patients and their carers, and the population as a whole.

The need to achieve and maintain a financially sustainable future for the

Trust and the local health economy.

The re-shaping of local health and social care services to prevent ill health and enable much more care, when it is needed, to be provided outside hospital, particularly for older people and people with long-term conditions.

Reconfiguration of hospital services across Greater Manchester

(“Healthier Together”).

The Trust Estate must provide building facilities and services infrastructure that effectively and efficiently support the key elements of the organisations’ Clinical Service Strategy, these being:

Bolton FT will build on the advantages of being an integrated provider of local hospital and community-based health services to deliver, with our partners, the very best care for Bolton patients throughout their healthcare journeys. We will focus on ensuring the best care for frail elderly people and people with long term conditions, outside hospital, through design and delivery of effective pathways of care.

Prevention, early intervention and keeping people healthy is central

to why we are here, as well as to provide excellent care for people who need treatment.

Royal Bolton Hospital will remain a major provider of A&E and

emergency access services.

The Trust will continue to develop as a centre of excellence for Women’s and Children’s services, remaining one of Greater Manchester’s hubs for those services.

The Trust will retain and develop a range of planned diagnostic and

treatment services which;

Can sustain high standards, have critical mass and are clinically viable; Meet the needs and preferences of patients; Make a positive financial contribution and/or; Are essential to sustaining the wider service provision in the Trust.

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3. Where Are We Now? The Land and Building assets that the organisation owns are currently valued at £110.8m. The Trust currently operates from a range of premises that vary from new high quality, fully functional premises, that are not fully utilised, to Victorian properties that offer poor quality in terms of decoration, comfort, functional suitably and backlog maintenance risks. Data on the performance of the organisation’s estate is limited. The Trust has undertaken property appraisal in terms of Building, Engineering, Statutory Safety and Fire Safety on an annual basis, which contributes to identification of Backlog Maintenance cost. The Trust has one of the highest Backlog Maintenance costs within the region, currently £23.9m which is risk adjusted to £11.95m. The risk adjusted figure is a calculation that takes into account high and significant risk whilst also acknowledging future maintenance cost for moderate and low risk. The Trust has an ageing building services engineering infrastructure, with identified high and significant backlog maintenance risk. The current main air cooled chilled water plant that provides refrigeration for the main Theatres Air conditioning plant has reached the end of its operational life. The equipment regularly fails causing operational difficulties in the operating theatres. Much of the heating infrastructure is inefficient and the current coal boilerhouse equipment is very maintenance-intensive, and performs poorly in terms of carbon emissions. During the past five years significant investment has been directed into the Electrical infrastructure which has included the procurement of modern stand-by generators. This is an area that could be explored to provide the Trust with potential income. In previous Estate Strategies reference has been made to disposal of the South East Sector of the site, however little progress has been made. Currently the large areas of the former Print and Laundry buildings are vacated and surplus to requirements. Areas such as Children’s Outpatients and Minerva Day Centre offer poor accommodation and these buildings have significant backlog. Premises within the community such as Halliwell Children’s Centre and Westhoughton Health Centre also provide poor facilities for patients.

5

In past two years the Trust has located some services into the health economy “Flagship” premises of Bolton One and Breightmet Health Centre. These two premises provide high quality functionally suitable environments. However, a recent week long space utilisation survey highlighted poor levels of occupation within these centres. In some areas, rooms had utilisation rates of below 30%. There has been some interest from a potential developer and another NHS Trust to buy land in the South East sector of the RBH site for health / social care related projects. A valuation of the South East Sector of the site has recently been undertaken by the District Valuation Officer. Land prices within the Farnworth area remain depressed, and the current valuation for this site is £2.75m The large proportion of the acute clinical services are located on the main spine of the hospital. Ward accommodation between A and D blocks was built in the early part of the twentieth century and this accommodation has been converted from original nightingale wards. Although B1 ward has recently been upgraded and A4 ward is currently undergoing refurbishment, the remaining accommodation feels tired and in need of refurbishment, although some work to provide improved infection prevention in these wards is currently ongoing. Recent upgrades to the Maternity Unit have provided first class Neonatal / Special Care and Central Delivery Unit facilities. However the remainder of the Maternity complex has high risk backlog maintenance issues in terms of fire safety and asbestos. Many of the ward area environments are looking tired, and these areas can be very drafty during the winter months due to poorly fitting metal window frames. The Major Development accommodation of E, F and G Block, which was built in 1996, remains in a generally good condition, although some of the engineering plant and equipment is in need of refurbishment, as this equipment is reaching the end of its normal life-cycle.

4. Where Do We Want to Be? The performance of the estate has traditionally been measured in terms of NHS Property appraisal criteria and Patient Environment Action Team (PEAT) / Patient Led Assessment of the Care Environment (PLACE) inspections. However these assessments don’t take into account functional suitability, space utilisation and energy performance. As a result the Trust has limited information on the performance of the estate.

6

Recent space utilisation audits of areas in Bolton One and Breightmet Health Centre provide an indication that as an organisation, we do not manage our space well. The new Estate Strategy must deliver a Trust estate that truly supports the Clinical Service Strategy, in premises that are functionally suitable, welcoming, comfortable and are utilised efficiently and effectively. The new (under-utilised) facilities of Bolton One and Breightmet Health Centre provides an opportunity to relocate services that currently operate within buildings on the Royal Bolton Hospital site, with poor environment and maintenance-related problems. This will allow a rationalisation of the hospital estate, allowing the demolition of buildings with low occupancy or with significant backlog maintenance issues, and enabling the sale/lease/re-use of surplus land within the South East sector of the Royal Bolton Hospital. All acute clinical services need to be located on the main spine of the Royal Bolton Hospital site, with a building service engineering infrastructure that is highly efficient, cost effective and fully meeting our carbon emissions reduction commitment. As part of the future, the Estates Capital Investment Programme will include the refurbishment of patient and public areas along the main spine of the hospital. During the next five years, the Estate Strategy and associated capital investment will deliver improvements in the following criteria achieving the highest possible performance for each standard of the NHS Land and Property Appraisal model (illustrated in table two) as set out on the next page.

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Physical Condition Achieve Standard B Sound – operationally

safe and exhibits only minor deterioration.

Functional Suitability Achieve Standard A Very satisfactory – no change needed.

Space Utilisation Achieve Standard F Fully used – a satisfactory level of utilisation.

Quality Achieve Standard B Facility requiring general maintenance investment only.

Statutory requirements Achieve Standard A Building complies with all statutory requirements and relevant guidance.

Environmental Management

Achieve Standard B 56 to 65 GJ per 100 cubic metres.

The Estate Strategy will also include two local additional criteria in which performance will be measured and improved these being:

Backlog Maintenance – Zero risk-adjusted Backlog Maintenance within five years.

Planned Preventative Maintenance – 95% compliance for

Maintenance Programme for each of the 15 identified critical systems i.e. water safety, fire safety and electricity, to be achieved as soon as possible, within three years.

8

5. How Do We Get There? Three organisations within the Bolton Health Economy have responsibilities for Property Management of Healthcare Facilities within Bolton. These are ‘Bolton NHS Foundation Trust’, ‘Bolton Clinical Commissioning Group’ and ‘NHS Property Services’. Each of these organisations have a different agenda for the management of healthcare premises in Bolton. It is important therefore that discussions take place between these organisations to identify and agree a process in which the levels of space utilisation both at Bolton One and Breightmet Health Centre can be improved. This will facilitate the rationalisation of the Royal Bolton Hospital site, with the relocation of services as illustrated in Table Three. It is currently proposed that all Children’s Outpatient Services, which currently operate from the Royal Bolton Hospital and Halliwell Children’s Health Centre would be centralised at Breightmet Health Centre. Currently, some Orthopaedic Out-Patient clinics operate from Minerva Day Unit. The Minerva Day Unit provides poor facilities for patients. It is planned that these Orthopaedic Out-Patient clinics will be relocated to Bolton One. These plans will be developed with representatives from each of the relevant services, facilitated through workshops that are supported by Divisional Directors of Operations, and representatives from Estates, Finance and, where appropriate, NHS Property Services. We aim to reduce the current level of risk-adjusted backlog maintenance to zero over the next five years. The rationalisation of the estate will be one contributer, but the building services engineering infrastructure needs significant investment to ensure that all clinical services are supported with reliable, efficient and well maintained heating and air conditioning plant. Work has already started to develop an energy scheme that fully addresses the identified risk, whilst providing reductions in utility consumption, carbon emissions and revenue costs. Potential energy partners have been identified and initial discussions are in hand. Capital funding in the region of £7m will be required. The scheme will however offer some pay-back with reduced energy cost estimated to be around £700K per annum. Once funding has been identified, an OJEU Competitive Dialogue process will be undertaken. It is anticipated that the energy scheme, with guaranteed annual savings, would be fully completed within three years. The rationalisation of the Royal Bolton Hospital estate could potentially release 54000 square metres of land in the South East sector of the site, currently valued at £2.75 m. There has been initial interest from one NHS Trust and a developer

9

to provide health / social related projects on this land. At this stage it must be noted that options to sell this land will be restricted due to a £3.2m loan for provision of car parking on approximately one third of this land. However, options to retain ownership of the land and enter into lease arrangements with third parties could be a viable option. The rationalisation of the estate will reduce the organisation’s maintenance cost, energy cost and capital charges. Currently, the energy scheme and potential development of the South East sector are being scoped as one project. If a district heating scheme is incorporated within the energy scheme to service the new development, this could also provide an opportunity for the Trust to generate an income from the sale of energy and other estates and facilities services. The new proposed Estate Strategy is ambitious and innovative. It is recognised that it is important that the Trust fully implements appraisal of the current Trust estate utilising the six facet NHS Land and Property Appraisal model (as illustrated in table two) and that this includes backlog maintenance performance and planned preventative maintenance compliance. Over the next five years, significant investment is required to improve the Trust estate and infrastructure. The performance of the Trust estate and infrastructure will be constantly measured to ensure that it fully supports the clinical services strategy and provides our patients and staff with pleasant, comfortable healthcare environments that are effective and efficient. Careful consideration will be required to be given to car parking on the Royal Bolton Hospital site. This will be an area that will be scrutinised by the Local Authority Planning Officer due to previous parking issues. Appendix One provides an illustration of the proposed changes to parking facilities. Discussions with Transport for Greater Manchester will also take place, to ensure the provision of reliable and frequent public transport to community health centres such as Breightmet.

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6. Recommendations The management of healthcare estate and property is complex. It is important that property assets support the clinical service strategy whilst providing premises that are aesthetically pleasing and comfortable for both patients and staff, also ensuring that all accommodation is functionally suitable and effectively and efficiently utilised. Currently there is only limited data on the performance of Trust-occupied premises, in terms of space utilisation, quality and functional suitability. It is important that any investment in the refurbishment of premises and upgrade of the building services infrastructure has a positive impact on the performance of the estate overall. This Estates Strategy is at an early stage of development with an emphasis on releasing surplus land and using space more efficiently, whilst improving Trust premises and reducing risk. It is recommended that discussions with key stakeholders including the CCG, NHS Property Services and representatives from potential premises users, both staff and patients, are undertaken immediately. Where necessary, the Trust will undertake formal consultation on any substantial service change judged to arise from the relocation of services. During these discussions it is also recommended that the NHS Land and Property Appraisal Model is adopted to ensure that any changes to the Trust estates and premises which the organisation occupies have a positive impact on patient staff experience, ensuring efficient and effective operation of Trust buildings and infrastructure for the full life-cycle of each building asset. A full business case and integrated implementation plan for the Estate Development, as outlined will be confirmed by March 2014.

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Table One – Total Backlog Maintenance Royal Bolton Hospital Site Only 2012/13 (@ 31st March 2013)

Condition High Risk (£000's)

Significant Risk (£000's)

Moderate Risk (£000's)

Low Risk (£000's)

Risk Adjusted (£000's)

Building

170 552 2,071 2,103 910

Fire 3,160 1,994 1,215 589 5,280

Statutory 90 1,976 2,281 729 2,220

Engineering 225 2,914 3,036 783 3,576

Total 3,645 7,436 8,603 4,203 11,985 Total Backlog Maintenance (£000's) £23,886 Total Risk Adjusted Backlog Maintenance (£000's) £11,985

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Table Three – Illustration of Proposed Relocation of Services to Rationalise Royal Bolton Hospital Estate. Current Service Current Location Proposed Future

Location

Skin Services Royal Bolton Hospital And Water Meeting Health Centre

Lever Chambers Health Centre First Floor

Centralisation of Skin Services to town centre location.

CAMHS Unit Royal Bolton Hospital South East Sector

Breightmet Health Centre

Release of Land (Royal Bolton Hospital South East Sector)

Minerva Day Centre Royal Bolton Hospital South East Sector

Bolton One Release of Land (Royal Bolton Hospital South East Sector)

Education Centre Royal Bolton Hospital South East Sector

Relocated Centrally on Royal Bolton Hospital Site

Release of Land (Royal Bolton Hospital South East Sector)

Bolton Sexual Health N Block Bolton One N Block to be used for Support Services Accommodation

Therapies N Block Bolton One N Block to be used for Support Services Accommodation

Finance Dowling House First Floor N Block Release of Land (Royal Bolton Hospital South East Sector)

Computer Services Dowling House + Data Centre One

Ground Floor N Block Release of Land (Royal Bolton Hospital South East Sector)

Children’s Out Patients Children’s Outpatients RBH and Halliwell Children’s Centre

Breightmet Health Centre

Demolition of surplus accommodation to facilitate future Visitors car parking following south east sector land sale.

Security Lodge House Shawcross House Royal Bolton Hospital

Demolition of surplus accommodation to facilitate future Visitors car parking following south east sector land sale.

Laundry Receipt and Distribution

Laundry Building Porters Receipt and Distribution

Demolition of surplus accommodation to facilitate future staff car parking following south east sector land sale.

Social Services Print Building Accommodation Block Three

Demolition of surplus accommodation to facilitate future staff car parking following south east sector land sale.

17

Current Service Current Location Proposed Future Location

Estates Services including Fire and Safety Department

Shawcross House / Davenport House

Silverhill Centre (N Block)

Demolition of surplus accommodation to facilitate future visitors car parking following south east sector land sale. Shawcross House being used to accommodate security/ transport and Central Stores

ISS Facilities Porters Receipt and Distribution D Block and Office Accommodation B Quarters

Accommodation Block Three

Allow relocation of Education Centre onto Main Spine of Hospital

Medical Secretaries / Physiotherapy Office Accomodation

B Quarters Musgrave House (Under Utilised Space)

Allow relocation of Education Centre onto Main Spine of Hospital

18

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APPENDIX D

Informatics Strategy – June 2012 Version 5.1

Author: Chris Cook, Interim Chief Informatics Officer

1. Document Purpose This document outlines the Bolton NHS Foundation Trust Informatics Strategy which has been approved in principle by the Board of Directors on 26 June 2012. For clarity, the Board approved all cost neutral actions, including a merger of the IT and Information teams1

This paper sets out a direction of travel in key strategic areas. A strategy implementation plan / roadmap will be developed and it is expected that this will evolve over time.

. All investments/projects which require funding over and above existing agreed budgets will need business cases to be approved as normal.

It should also be noted that there is much work ongoing in the IT and Information teams that is not included here. This does not indicate that this work will stop or that it is not important. However, all current and future activities will be reviewed to ensure they align with this strategy – this paper is a first draft and the strategy will be updated as required.

2. Executive Summary This document summarises the strategy for Informatics for Bolton NHS Foundation Trust over the next 5 years. Informatics is the term that is becoming widely used in the NHS to cover the IT and information management functions.

In 2011, Amor Group was commissioned to review Informatics at the Trust. This strategy document builds on the key recommendations made by Amor, and endorsed by the Board of Directors in October 2011, including the proposal to integrate the current IT and Information functions into a single department.

The Trust is undergoing a period of unprecedented change and is now entering the new world of commissioning and competition, with staff and patients who have ever higher expectations of how the NHS should be using technology. At the same time, in a period of scrutiny by Monitor, the quality of the Trust’s management reporting has been found to be lacking.

This strategy seeks to support the Trust in the challenges it faces, to help develop the reputation of the Trust and to enable it to meet its objectives. The strategy also aims to align Informatics development at BFT with the objectives set by the Department of Health’s Power of Information strategy for Informatics in the NHS (May 2012) which highlights technology as being a critical enabler in the provision of care quality over the coming years.

This strategy document proposes action in the following areas:

1. Integration of IT and Information to create an Informatics department. 2. A shift from data production to the provision of “business intelligence” (for example,

improved analysis for divisions and Board reporting). 3. The development of Clinical Informatics to support efficiency, care quality and mitigate

clinical and information governance risks, with a long term aim of an Electronic Patient Record.

4. The use of mobile technology to support care quality and to enable flexible working. Innovative use of mobile technology would enhance BFT’s reputation and could also support achievement of CQUINS and the avoidance of contract penalties.

1 Subject to clarification regarding the current round of cost departmental reductions

Informatics Strategy

Informatics Strategy 22/10/13 Page 2 of 14

0%

1%

2%

3%

4%

5%

Industry Norm

NHS Avg Bolton FT

IM&T Spend as % of Annual Revenue Spend

5. Responding to the challenges of commissioning and competition: eg service level reporting, providing integrated systems for GPs.

6. The integration of Community Services IT and information reporting 7. IT infrastructure requirements, in particular, the need to invest in wireless networking, PC

upgrades and investment required for telephony 8. Business engagement: the Informatics team must engage effectively with the organisation to

ensure IT systems are used to optimise business processes and care delivery and management information is accurate and timely.

9. The development of an Informatics Service Delivery capability that provides a professional, service level-based support service based on best industry practice and with a commitment to continuous improvement. Once established, the service can be benchmarked against third party service providers with a view to outsourcing if a more cost efficient and higher quality service can be provided externally.

10. Implement best practice Informatics governance, including a project management methodology (aligned with that being developed in BICS).

3. Background The Trust is undergoing a period of unprecedented change. In July 2011 it took over responsibility for Community Services in Bolton, including an additional 1,600+ staff, from the Primary Care Trust and it is now gearing up to the new world of commissioning and competition for health service provision. In the last 6 months the Trust has also been challenged by its own Board and by Monitor over the quality of its management reporting.

The Trust, and the NHS in general, faces a growing challenge in information governance (for example the use of paper based patient records in the hospital and across community services) as well as growing technology expectations of staff and patients (for example, the use of mobile technology). Clinicians see other trusts as more advanced than Bolton – for example, Salford Royal has been using an Electronic Patient Record system for 11 years.

In 2011, Amor Group was commissioned to review Informatics at the Trust. Their report, presented to the Board of Directors in October 2011, highlighted that investment in IT at Bolton was running at less than half the national NHS average.

Amor made a number of recommendations, including:

Integration of the IT and Information teams into a single department

Aim for an Electronic Patient Record … reusing many of the investments made

Invest in and enhance the IT Service Desk to improve the IT support service

Etc

This paper outlines an Informatics strategy that will provide effective support to the Trust in meeting its corporate objectives and in addressing the challenges it now faces, including expectations of staff and patients. The strategy also seeks to implement the key recommendations made by Amor.

The strategy also aims to align Informatics development at BFT with the objectives set by the National Commissioning Board’s Power of Information strategy (May 2012) for Informatics in the NHS which highlights technology as being a critical enabler in the provision of care quality over the coming years and sets a goal of patients being able to access their own medical records by 2015 (albeit GP records in the first instance).

Amor Report, Oct 2011



4. Vision The Informatics service at Bolton NHS Foundation Trust will have a vision as being recognised as one of the most proactive, innovate and customer focussed Informatics services in the NHS. It will be professional and well governed. It will be an integral part of the organisation. It will be a key enabler of the Trust’s objectives and it will be an exemplar for the Department of Health’s information strategy, The Power of Information.

5. Building Blocks Despite a lack of sophistication in clinical informatics, the Trust has made a number of astute investments in IT in recent years:

It has a world-leading integration engine (InterSystems Ensemble) which enables systems to communicate to each other (for example the patient administration system sends patient demographics, via the integration engine, to departmental system such as Pathology, Radiology, Theatres etc)

It has a best of breed data warehouse (SAP Business Objects) for management reporting

It has a modern, resilient data network on the hospital campus and two data centres

It has on-line links to GP practices, including diagnostics ordering and electronic discharge correspondence

It has established the capability to support secure flexible working using a variety of mobile technologies

It has designed and has started to implement an innovative “virtual desktop” to enable fast deployment and centralised management of “thin client” (low energy) PCs

These building blocks, aligned with existing technical skills in both the IT and Information teams, provide a sound foundation for the development of strong Informatics capability.

6. Strategy Overview

This section outlines the key areas of the Bolton FT Informatics strategy. For each area, quick wins have been identified along with medium and longer term proposals, which will require more detailed planning and costing. Individual business cases will be developed for the component projects that will be required to deliver the strategy.

6.1 Creation of an Informatics function

A key proposal from the Amor report was the integration of the current IT and Information teams to form a single Informatics team. There are clear benefits from this including:

A joint approach to improving data accuracy (and hence the quality of health records and management reporting) through improved operational processes and training (in conjunction with “system owners” in the Trust)

Shared functions, such as business engagement, service desk and project management

Section 7 below outlines the approach to achieving the organisational change required.

Key Hospital Systems



6.2 Business Intelligence

The development of a data warehouse has fuelled a growing demand for management reporting. The current Information team face a constant barrage of requests for data reports. There is currently little capacity to provide value-added activities, such as data quality improvement or intelligent analysis of information, particularly with respect to key operational and clinical performance indicators.

The Information function must move from producing reports and data to become a trusted Business Intelligence advisor. This will be achieved through:

1. A focus on the key operational and clinical performance indicators, particularly Board reporting and analysis and the provision of the new Performance Assessment Frameworks.

2. Improved business engagement, including monthly reviews of Board reporting and PAFs with divisional teams. Informatics will provide reporting and analysis, though divisions will retain ownership of the data.

3. The development of data analysis tools for end users (for example, QlikView) 4. The development of a report request process to control, prioritise and plan the production

of ad-hocs reporting

The Informatics team will provide leadership for ensuring the accuracy and integrity of management information by working with “system owners” (see Business Engagement below) to develop standard processes for the use of IT systems and in particular the capture of data. Informatics will work with system owners to agree training requirements and also ensure staff follow standard processes and enter data accurately (through auditing, training and supporting performance management).

The Informatics team will retain responsibility for clinical coding and will continue to ensure the highest quality of coding. The Informatics team will also work proactively with users of medical records to minimise the level of uncoded activity.

Quick Wins

Improved Board reporting (starting in June) Establish monthly report production timetable, incorporating Andy McGrath’s Performance

Assessment Framework (from June) Agree action plan to eliminate uncoded activity (July) Establish monthly divisional and CCG reviews business intelligence reviews in line with the

new COO’s requirements (June/July)



Allow data warehouse users to obtain reports in more flexible formats, eg Excel rather than just PDF format – subject to further discussion ! (July)

Medium/Longer term actions

Develop the QlikView application (already procured to support the Patient Level Costing project) to provide an end user data analysis tool

Review processes and training requirements with system owners with the objective of improving the quality of data capture

Develop professional customer reporting (eg for CCG, AQP customers)

6.3 Clinical Informatics

A fully integrated Electronic Patient Record (a completely paperless operation) is the Holy Grail but it will take a long time to achieve. Replacing all the current systems with a complete EPR solution would be a major financial investment and would cause significant disruption to the Trust.

The Trust should take a pragmatic, step by step approach to Clinical Informatics with a long term aim of achieving an EPR. The approach should be guided by what can be practically implemented and what provides the biggest benefit, including initiatives that will support the reputation of the Trust. Success will also depend on clinical engagement and support.

It is strongly recommended that a dedicated Clinical Lead be appointed to steer the Clinical Informatics strategy and to ensure the support of fellow clinicians, certainly before Step 2 below is initiated. A dedicated Clinical Informatics project manager will also be required.

Current best of breed clinical systems should be optimised with standard operating processes and development plans agreed jointly between Informatics and system owners. Key clinical systems include:

Step 1 – Optimise Current Best of Breed Systems and address process inefficiencies

ExtraMed (bed and patient flow management system) RIS and PACS (Radiology Information and Digital Imaging systems) CliniSys and LabCentre Pathology systems Ascribe, pharmacy system Ormis, theatre system Euroking, maternity system

Clinical engagement must be sought to improve operational efficiency, for example the strategy for electronic ordering and the efficiency of IT systems in key operational areas such as A&E.

Nursing staff currently enter ward discharge or transfer data twice: on ExtraMed and again on the PAS (Patient Administration System) – this is inefficient and also causes mismatches in bed occupancy and discharge reporting data. PAS suppliers, CSC, have now proposed a fix to allow ExtraMed to automatically update the PAS (via our Integration Engine).

The Trust has developed on-line discharge reporting from the Ascribe system, with discharge letters sent electronically to GPs. Technical issues and adherence to standard operating procedures by clinical staff must be resolved in order to avoid further penalties for missing GP correspondence targets.

Nursing staff use multiple systems to collect data such as Harm Free Care measures. Data collection and reporting processes will be analysed and simplified, potentially with the aid of hand held devices (see Mobile Technology below).

Finally, the case for the introduction of electronic prescribing should also be examined. This too will require clinical leadership.



Paper based medical records present both a clinical risk (eg paper records not always being available) and an information governance risk (eg loss of paper records). These risks are now exacerbated by the requirement to transport medical records across community services.

Step 2 – Electronic Document Management for patient records

In addition to risk management, there would be a number of financial benefits to the use of an Electronic Document Management System (EDMS), including:

Cost savings in records storage and records management Reduction in uncoded activity (lost revenue for 2011/12 is estimated at £1m) Time saving for doctors and nurses Ability to fill cancelled slots (currently, in community services, medical records have to be

ordered two weeks in advance of an appointment – if a patient cancels an appointment there may not be time to order records for another patient to fill that slot).

EDMS would be a significant investment (c. £1m) and would require a major change programme that would affect every doctor and nurse in the Trust. St Helens and Knowsley NHS Trust has published figures from the EDMS implementation showing an overall investment cost of £1.2m and a saving of £600k pa.

It is proposed that a review of best practice in the use of Electronic Document Management systems by NHS trusts be undertaken, with a view to developing a business case and implementation plan for Bolton NHS FT (significant work has already been done by Sarah McDonald). A dedicated Clinical Lead and Clinical Informatics Project Manager are required.

EDMS can provide a system to manage paper records but it does not provide a fully integrated electronic patient record system covering all aspects of a patient’s care pathway.

Step 3 – An electronic patient record system (EPR)

It is recommended that a team is formed to evaluate the requirements for an EPR (this could be the same team formed to lead the EDMS project above). Included in their remit must be to review the requirements of Community Services and the requirement to provide integration to local authority systems, for example social services records. The review should also incorporate the objectives of the DH’s Power of Information strategy, such as the ability to share patient records with other carers (eg GPs) and ultimately to make care records available on-line to patients.

It should be noted that most EPR systems on the market are focussed on the requirements of acute care providers so a standard, best of breed EPR may not provide the best solution for Bolton FT. A portal solution which allows access to departmental systems (eg pathology results) should be considered either as a forerunner to a full EPR system or as a core part of an EPR solution.

Although the development and implementation of a full EPR is a long term strategy, evaluation work should be started now to ensure that care quality through the use of an EPR can be achieved as soon as possible and to ensure that the reputation of the Trust is enhanced by the visibility of its planning for the future.

Such an evaluation must be clinically led. To ensure a consistent approach, it is recommended that EDMS and EPR are led by the same Clinical Lead, supported by an appropriately qualified team and a dedicated Clinical Informatics Project Manager.

Medical Records



The approach to Clinical Informatics can be summarised as follows:

Quick Wins

Establish system owners (expert end users), Informatics owners and user groups for key clinical systems, then agree development and process optimisation plans

Upgrade ExtraMed to the latest supported version Agree an action plan to address discharge correspondence issues [this has been initiated,

using consultancy from Ascribe] Initiate a BICS (Bolton Improving Care System) review of Informatics in A&E and the new

CDU to look for efficiencies and improvements and also to gain clinical engagement [planned to start on 16 July]

Develop the strategy for online diagnostics ordering (to agree how we deliver this prior to the implementation of a full EPR system, in particular do we push on with the iCM system?)

Work with the PACS Manager to initiate the first stage of a plan to move PACS support away from NHS National Programme contract with CSC (which ends in June 2013), including localisation of diagnostic images (migrated from CSC’s data centre) and contracting through the Greater Manchester PACS consortium for a new maintenance and support contract

Review Harm Free Care and other data collection requirements by nurses and evaluate the potential for using mobile devices (see also Mobile Devices below)

Re-establish the Clinical Advisory Group with a remit to develop the Clinical Informatics Strategy

Appoint a dedicated Clinical Lead for Informatics

Medium/Longer term actions

Implement automatic discharge/transfer updates from ExtraMed to PAS (to enable real-time bed occupancy and discharge reporting and to save nurses having to double enter data)

Initiate a review of best practice in the use of EDMS systems by NHS trusts, evaluate suppliers and develop a business case and implementation plan for Bolton NHS FT (clinically led)

Initiate the evaluation of requirements for an EPR, including Community Services, GP and local authority requirements (clinically led)

Evaluate the potential for using e-Health technology to support patients in their own homes (rather than needing to stay in hospital)

6.4 Mobile technology

The use of mobile technology will be evaluated to support care quality and to enable flexible working. Innovative use of mobile technology would enhance BFT’s reputation and would also support achievement of CQUINS and the avoidance of contract penalties. It also requires a relatively low investment and can be deployed in a matter of months. Compelling business cases for the uses of mobile technology for patient care may also attract funding from the PCT (this year only!).

The Trust should also enhance its reputation and support efficiencies enabled by flexible working. Access to systems would be based on a secure, “any device” basis. For instance, clinicians should have the ability to synchronise diaries with their smart phone, managers should be able to do their work from Trust PCs, Trust tablets or their own home PCs or tablets and staff should be able to access email and Intranet on their home PCs or their own mobile devices.



Quick Wins

Develop business cases, including technology proposal, for the use of mobile technology to support a number of requirements:

Management of patients with strokes Data collection for Harm Free Care Pre and post-natal maternity care management Data collection and alerting for patient deterioration Collection of patient satisfaction surveys

Evaluate requirements for flexible working and use of mobile technology by staff, clinicians and management. Start with the requirements of directors and senior manager in order to cost the set-up, implementation and ongoing support required.

6.5 Competition / Reputation

Informatics will play a key role in supporting the Trust’s reputation and providing a competitive edge in the marketplace. In particular through:

The support of web and on-line developments The development of support services for CCGs and GPs The provision of accurate and professional management information reporting for service

commissioners

Quick Wins

Commission an external web design company for the new BFT web site [in progress] Develop relationship with CCG and understand their reporting and IT requirements Roll out on line diagnostic image viewing (PACS) for GPs Gear up Business Intelligence reporting to cope with the anticipated demand for customer

service level reporting

Medium / Longer Term

Provide access to patient records to GPs Provide access to patient records to patients Offer a managed Informatics service to CCG and GPs

6.6 Community Services

There is still much to be done to integrate Community Services Informatics systems into those of the Trust:

Over 1,000 staff still have both BFT and PCT email accounts Access to BFT Intranet and other systems is slow & clunky PCT PAS (patient administration system), ExtraMed (patient flow) and other applications are

still in use and supported by the PCT The PCT still supports telephony at community sites Free PCT IT support stops on 1 April 2013

Only one community site, Bolton One has been integrated into BFT’s IT network. 30+ sites remain to be connected to BFT’s network. However, Bolton One has provided a template for other community sites comprising: modern “virtual desktop” PCs, a single email system and a fast network connection to BFT’s data network.



A project has been initiated with the PCT’s Interim Associate Director of IM&T to enable the completion of the Community Services IT integration. There are three key issues to resolve to ensure a successful completion:

Central coordination of which clinical services are moving to which community buildings and when is essential to inform IT planning (also required by Estates)

Costs need to be agreed and approved, including resource requirements (project management and engineers)

The migration of patient data from the PCT PAS (Lorenzo) to the Trust’s PAS (LE2)

Quick Wins

Appointment of a Community Services Development programme manager to coordinate all aspects of clinical service moves [through BICS PMO? – currently under discussion]

Migrate all PCT email accounts to BFT email for all Community Service staff [August] Initiate Community Services site surveys to agree IT requirements [started] The development of a costed proposal, including resource requirements – funding to be

sought from PCT? Agree and communicate the approach for the migration of patient data from the Community

Services’ PAS to the Trust’s PAS


Complete the migration by 1 April 2013: - Implement data network connections to all community sites - Upgrade PCs and printers - Applications to move to BFT network and support service - Migrate Lorenzo patient records to the Trust PAS - Migrate PCT ExtraMed to BFT’s instance - Software licences to be novated to BFT - Migrate PCT applications to BFT Informatics Service Desk support

Procure and implement Voice over IP telephony system at community sites (to be agreed

with Estates) - to replace PCT phone system - to utilise data network (eliminating line rental and internal calling costs) - with capacity to replace RBH telephone system when the current contract expires

6.7 IT Infrastructure

The Trust has a sound IT infrastructure base with a high bandwidth, resilient data network with two on-site “data centres” on the hospital campus. However, many PCs and printers are old and need replacing.

A modern, fast “virtual desktop” has been developed which can utilise power efficient “thin client” PCs. It has been successfully piloted at Bolton One and is now ready to be deployed throughout the hospital and across community sites.

The potential for using a managed printer service, and the level of cost savings available, should be explored as an alternative to retaining and upgrading existing printers.

The current wireless network is at “end of life” (no longer supported), it has a limited range, it is not available in all areas of the hospital and it is only designed for use by staff (using the internal data network). Investment in a new wireless network is proposed to enable flexible working and also to



provide patients with wi-fi Internet access. This investment is also a pre-requisite to support the use of mobile devices in the Trust.

A single sign-on capability will be developed to provide easier access to the multiple systems used across the trust.

A plan will also be developed with Estates for the implementation of a new (Voice over IP) telephony network to replace the current Trust telephony system with a modern system by the time the contract to support the current legacy system expires (2015).

See also Community Services for the requirement to integrate community sites with the BFT IT network.

Quick Wins

Develop business case and implementation plan for standardised “virtual desktop” PC roll-out

Seek approval for existing business case for wi-fi network Evaluate case for a managed printer service Evaluate Single Sign on requirements


Roll out virtual desk PC upgrades (2 to 3 year project) Roll out new wi-fi network (12 month implementation) Roll out Single Sign On Replace telephony system (2012/2013)

6.8 Business Engagement

Lack of Clinical Engagement was a key finding in the Amor report, but there is currently insufficient Informatics engagement across many areas of the organisation. It is a key requirement of the Informatics function to ensure it is engaged at all levels across the organisation. Any component of the Informatics function which does not need to be engaged with the organisation could be considered a commodity function and may therefore be considered for outsourcing.

Business engagement will be addressed at a number of levels:

Informatics should be represented at the Executive Board (by the CIO) and at Divisional Boards by new Divisional Business Manager role to be created as part of the proposed new Informatics organisation (as per Workforce and Finance Divisional Managers) – [this proposal is still subject to budgetary agreement]

Informatics experts will work with system owners for all key systems to manage user groups and agree system developments, training requirements and process optimisation initiatives

With the possible exception of IT infrastructure projects, informatics projects (or informatics workstreams of other projects) will be managed jointly with business leaders and Informatics project managers (see Governance below)

Informatics will engage with customers to support service delivery (eg CCG, GPs, AQP customers)

Informatics will work with an appointed Clinical Lead and the Clinical Advisory Group to develop and deliver the Clinical Informatics strategy

Quick wins

Establish System Owners (expert end users) for all key systems Establish Informatics experts for all key systems



Establish user groups for all key systems Establish clear roles and responsibilities for System Owners Informatics Divisional Business Manager to be appointed [subject to budget approval] in a

new Informatics organisation structure: - to represent Informatics at Divisional Boards - to be agree monthly Board reporting and analysis with Divisions - to ensure Informatics Service Delivery aligns with Divisional requirements

6.9 Informatics Service Desk

The current IT Service Desk handles 300 calls a week with a team of 4 people. This does not represent all IT support calls as some issues are reported directly to system owners or to trainers.

The 4 Service Desk agents may solve simple queries, but in the main they pass issues and service requests to the IT Technical Services team and others (including 3rd parties). They have limited tools for managing the calls, no service levels and no authority over the other teams who are tasked with solving issues or fulfilling service requests.

Customer perception now (and at the time of the Amor report) is that service is unpredictable and often slow, though the Service Desk staff themselves demonstrate a good customer service attitude and the feedback on the engineers who resolve issues is good.

The Customer Service Desk is Informatics’ “shop window” and it is central to the Informatics function. It will be developed to ensure it has the tools, processes and authority to be able to provide a professional, process-driven, measurable, customer service focussed support function for the Trust.

Quick Wins

Benchmark current customer satisfaction levels using a “Survey Monkey” email survey to BFT staff (run this every 6 months to measure perception of service)

Initiate a service improvement plan, based on establishing key metrics, monitoring metrics on a weekly basis and taking appropriate actions to improve them, including:

- Training to enable 1st line service desk agents to be able to fix more issues themselves without the need to pass on the calls to Technical Services engineers

- Providing the visibility to manage and action unresolved issues - Assess service delivery productivity and actual resourcing requirements - Extend desk hours and provide better coordination between 1st and 2nd line teams

Key support processes to be documented Service Desk system requirements to be evaluated with a view to implementing an improved

management system


Service catalogue to be developed and service performance metrics established Informatics Service Desk to take responsibility for administering user access to all key

applications as part of a joined up Workforce starter/leaver/mover process Development of an Informatics Service Delivery capability that provides a professional,

service level-based support service based on best industry practice (ITIL) and with a commitment to continuous improvement

Benchmark against outsourced service providers with a view to outsourcing only if

Evaluate the potential to provide Informatics services to CCGs

a more cost efficient and higher quality service can be provided externally



6.10 Governance

The IM&T Committee will continue to oversee the provision of Informatics to the Trust and will continue to report to the Executive Board.

All Trust projects that require investment in Informatics (eg new IT applications, new IT hardware, new reporting requirements etc) or changes to existing Informatics provision must have that Informatics component approved at the IM&T Committee.

It is proposed that an Informatics project management function be created to manage project planning and delivery. Informatics project progress will be reported to the new BICS PMO (Project Management Office) alongside, or as part of other business projects, and all Informatics projects will report progress monthly to the IM&T Committee.

A standard project methodology will be agreed with BICS PMO - for use on Informatics and all other BFT projects in order to ensure a common approach across the Trust.

Project management and implementation resource should be costed into project proposals in order to manage incremental investment costs and to avoid a dependency on Informatics support staff.

The Information Governance (IG) function will remain with Informatics. It too will develop key service metrics. The IG function will also develop the capability to gain ISO27001 Information Security certification in order to demonstrate our IG capability in support of the Trust’s reputation.

Ann Schenk will remain as the Senior Information Risk Owner and as such will continue to chair the IG Committee, in order to provide a non-partisan challenge to the Informatics IG function.

The Informatics function will be managed professionally, with a strong customer focus and a philosophy of continual improvement. In particular, staff will be managed and developed in a professional manner in accordance with the Trust’s Workforce practices.

Quick Wins

Professional documentation and standard templates will be developed and identified as “Informatics” documents

Monthly reporting will be established for all Informatics managers (from June) Agree a standard project management methodology with the Head of BICS and ensure all

Informatics projects conform Report project progress to BICS PMO and IM&T Committee (monthly) Due diligence on Informatics contract commitments Development of an Informatics project management and planning function Development of IG metrics


Gain ISO27001 certification for Information Security



7. Organisational Change

The IT and Information teams with be integrated into a single Informatics function capable of delivering the strategy outlined above.

7.1 Plan

A consultation plan is being developed with Workforce. The Chair of Staffside has also been notified.

It is proposed to manage the reorganisation in two phases:

Phase 1: Establish the new Informatics management structure

1. Propose new Informatics management structure and commence consultation on the proposed structure with IT and Information managers

2. Complete consultation with managers and establish the new Informatics management team

3. Communicate the establishment of the Informatics team and its strategic priorities and leadership responsibilities (+ change of name on documents and Intranet etc).

Phase 2: Review overall Informatics team

1. The new Informatics management team to review the resource and skill requirements needed to deliver the strategy

2. Propose any changes required and consult with any staff members who would be affected by the proposed change

Timescales to be agreed with Workforce.

7.2 Criteria for the new Informatics structure

The proposed approach will be cost neutral2

The organisation should have as flat a management structure as possible to support teamwork and to optimise communication.

. Additional resources, such as project managers and clinical leads will be identified and costed as part of business cases for component projects of this strategy.

The organisation must include leadership to focus on delivery of the key components of the Informatics strategy.

2 Corporate savings targets to be confirmed.



8. Next Steps Action Quick Wins (ongoing) Commence consultation with managers over proposed new management structure (July) Development of an action plan and roadmap to deliver the strategy (July) Budgetary costing and prioritisation of strategic projects (July-August) Recruitment of a permanent Chief Informatics Officer (by November)

APPENDIX E

BOARD OF DIRECTORS

6TH June 2013

BRIEFING PAPER - WORKFORCE STRATEGY

1.0 PURPOSE

The purpose of this paper is to provide colleagues with an overview of what has been achieved from the Trusts Workforce Strategy 2012 – 2017 one year on and the suggested key actions for the next 12 months as requested at the Board of Directors in April 2013.

2.0 BACKGROUND

The Trust launched its initial Workforce Strategy in April 2007 following a number of focus groups held with staff and the then PPI forum to ensure that it responded to the real issues for staff and patients. This strategy was then replaced with our current Workforce Strategy 2012 – 2017, which was agreed at the Board of Directors in June 2012. This strategy set out the Trusts vision, aims and objectives in creating a ‘Great Place To Work’. It outlined how the Trust aimed to achieve this vision, through the development of a responsive and flexible workforce in the way that it worked and in improving the quality and experience of the patients through effective development in capacity and capability. Integral to the Strategy are five key themes which provide the core requirements in creating a great place to work.

3.0 CURRENT POSITION

It is important to highlight that since the development of the revised strategy in 2012, the Trust has experienced significant internal and external changes and challenges including:

Turnaround. Healthier Together. Staff and patient survey outcomes. The Francis Inquiry and subsequent report. Trust Annual Planning and Corporate Objectives 2013.

In light of organisational changes and challenges it has been vital to revisit the key objectives, priorities and milestones for the Workforce Strategy.

The Trust has made significant progress in response to the existing strategy within the last 12 months including:

Production of a workforce matrix which has now been further developed to

include patient outcome data and act as an Early Warning Matrix for quality. Implementation of additional staff support mechanisms including mental

wellbeing and managing stress support in response to organisational change brought on by the Turnaround process and other service changes.

Sustainment of appraisal performance including the improvement in the quality of appraisals supported by refined and simplified documentation.

Launch of the Trust Core Values within the Trust, integrating these into HR processes including recruitment and appraisals.

Positive evaluation and reviewed of staff learning and development programmes including clinical and medical leadership.

Improvement in the recruitment and selection process based on competencies and behaviours, ensuring we a recruiting staff with a caring and compassionate approach.

Provision of additional learning and development opportunities to update skills and increase capability and flexibility of the workforce.

Continuation of Staff Engagement including the Engaging Manager programme, Big and Small Conversations and evaluation of the Temperature Check.

4.0 KEY ACTIONS

It is vital that focus is maintained on creating a Great Place to Work, particularly during a time of transition and transformation. The top five practical actions to develop the workforce, as requested for by the Board of Directors include the following:

1. Renewed focus on the development of a transformational culture that

creates one culture for the integrated organisation, working with teams across the community and hospital in developing more streamlined care pathways, fusing together the skills of the workforce thus developing a more blended team focused on high quality patient experiences.

2. Assessment of current leadership, management capability and competence. In light of the assessment, review and improve the current provision of management, leadership development programmes, learning opportunities, ensuring alignment with the gaps highlighted as part of the assessment.

3. Increased focus on the development of the unqualified workforce, including

Healthcare Assistants and Practitioners in respect of core basic skills alongside appropriate attitude and behaviour.

4. Continue to build and consolidate a high performing and inspirational

culture; ensuring staff are clear what is expected of them in relation to performance delivery standards and improvement, developing a performance assessment framework which links incremental progression to performance, recognising and rewarding accordingly.

5. Ensure staffing levels are appropriate and take into account the dependency

and acuity of patients, alongside more robust and effective rostering of staff, ensuring the right skills at the right time in the right place. Continued development of roles and contracts of employment to support the contingent workforce concept.

5.0 CONCLUSION

Significant progress has been made in the implementation of the first year of the refreshed Workforce Strategy in spite of challenges that have faced the organisation. This has been demonstrated in the sustainment of staff engagement within the organisation as evidenced in the 2012 staff survey. During such a substantial time of unprecedented change and workforce reduction, it is vital that the Board remain committed to the aim of creating a great place to work. Staff satisfaction has a direct correlation with patient satisfaction, therefore is it remains vital that we continue to live the core Trust

values with our patients and staff at the heart of everything we do, valued, respected and proud. Never has it been more important to continue and build upon the staff engagement work, engaging staff in things that affect them alongside implementing new ways of working and responding to the reductions in the size of the workforce. Change is constant and inevitable, therefore we need to develop a culture that embraces change and supports cultural transformation for the benefit of our patients, their families, carers, stakeholders and for our staff.

6.0 RECOMMENDATIONS It is therefore recommended that the Board of Directors:

Endorse the five key actions for 2013-14. Support the cultural transformation work required for the integrated

organisation. Embrace the need for visibility with our staff and patients, listening and

hearing their voice and acting proactively on information provided.

NICKY INGHAM DIRECTOR OF WORKFORCE AND OD

May 2013

Workforce Strategy 2012 – 2017 1

Valued, Respected, Proud

Our Workforce Strategy 2012-2017

Version 3


CONTENTS

PAGE

INTRODUCTION 3 OUR VISION, VALUES AND AIMS 4 HOW WILL WE LIVE THE VALUES THROUGH OUR WORKFORCE STRATEGY 5 WHAT DO OUR STAFF WANT AND HOW WILL WE REPSOND 6

THE CONTEXT OF OUR PLANS 10

External Context 10

Trust Context

Vision and Values

Governance

Workforce Planning

Partnership and Engagement

Equality and Diversity

People Management

Social Responsibility

Transform processes that promote effective working and use of technology

Robust performance development review an support

Effective Learning and Development

10 10 12 12 12 13 14 15

15 16 16

ACHIEVING VALUED, RESPECTED AND PROUD FOR OUR STAFF – OUR WORKSTREAMS 22 Workstream One – Effective Leadership, engagement and accountability

22

Workstream Two – Versatility of the Workforce to realign and transform as services change

23

Workstream Three – Flexible Working – matching capacity with demand

24

Workstream Four – Embed the Values into the way we do things

25

Workstream Five – Caring for the health and wellbeing of our staff

26

MEASURING SUCCESS 28 NEXT STEPS 29

CONCLUSION 29

APPENDIX ONE – WORKFORCE STRATEGY KEY MILESTONE PLAN 30


INTRODUCTION

Bolton NHS Foundation Trust’s vision is to match the best integrated care organisations internationally for the quality and efficiency of our services by 2016. Figure 1 summarises our vision, values and aims whose delivery this workforce strategy supports. We want to be known for the safety, effectiveness and compassion of the care that we provide. Our aim is to create a great place to work and the best place to receive care by ensuring that our staff feel valued, respected and proud and that we are putting patients and staff at the heart of everything we do. Our strategy outlines how we aim to achieve this aim. This Workforce Strategy builds upon and continues the priorities set out by our 2007 strategy. It recognises that there is still much to do for our patients and our staff, in achieving our vision of a great place to work. The NHS landscape is forever changing and the context within which we are operating as a Foundation Trust. In particular how our workforce operates is changing as a consequence of ‘Equity and Excellence Liberating the NHS’ which was published in July 2010. We will experience far greater competition for the services we provide and the people we employ alongside responding to the challenging economic position. Never has it been more important to continue the staff engagement work in engaging staff in things that affect them alongside implementing new ways of working and managing reductions in the size of the workforce.

As with our previous Workforce Strategy, we feel it is essential that our staff are directly involved in the development of our reviewed Strategy, ensuring that it fully reflects the needs and aspirations of our workforce. This is of particular significance given that the organisation integrated with the PCT Provider Arm and became a centre of excellence for the provision of Women’s and Children’s services. Staff engagement is essential to ensure that our Workforce Strategy responds to the real issues and concerns facing staff. A number of key themes have emerged from our focus groups with staff. They included:

Better forward planning of staffing requirements with the right number of staff in the right place doing the right job.

More flexible working options, matching capacity with demand.

More workforce wellbeing and emotional support.

Better quality appraisals

Feeling more valued by their managers and colleagues. Our strategy draws on the views of staff and their representatives as expressed through engagement events, staff surveys and departmental action plans. The focus of our strategy is to develop the Trust to attract, retain and develop an integrated, responsive and flexible workforce that consistently delivers best possible care for our patients. The delivery of our strategy will provide us with a workforce that is flexible, responsive, understands their role, is focused on delivering high quality services, that is innovative and has the patient at the heart of everything they do.


OUR VISION, VALUES AND AIMS

VALUES

Patient and staff at the heart of everything we do - how we behave, our attitudes and behaviour towards our patients and each other.

To be valued – striving to provide a quality service and taking responsibility for making improvements.

To be respected – treating everyone as we would want to be treated with dignity, courtesy and respect.

To be proud – showing appreciation to one another and positively promoting the reputation of the Trust as the place to receive care and to work in.

AIMS - TRUE NORTH GOALS

Best Care for Better Health (for our patients and our community) Valued, Respected and Proud (staff, patient and public) Responsible Use of Resources (for the taxpayer)

FIVE YEAR BREAK THROUGH OBJECTIVES

To match the best in our class of NHS organisations To provide access to services on demand and in response to the needs of our

patients To provide the highest quality service and outcomes for our patients and their

families

VISION By 2016 we will match the best integrated care organisations internationally for the quality and efficiency of our services. We want to be known for the safety, effectiveness and compassion of the care we provide.


HOW WE WILL LIVE THE VALUES THROUGH OUR WORKFORCE STRATEGY Patients and Staff at the heart of everything we do by:

Recruiting the best staff through robust processes ensuring our workforce align with the values and live them everyday.

Developing our workforce to realise their full potential through the provision of learning opportunities for staff at every level.

Delivering robust services that provide best possible care for our patients. Supporting the completion of mandatory training for all staff across the organisation

ensuring they are up to date and are providing safe care for our patients. To be valued by:

Supporting recognition of all members of staff encouraging a simple ‘thank you’ for a job well done.

Recognising that we all have a part to play in improving our services. Taking individual and collective responsibility to continually improve services for our

patients, their carers and their families alongside services to each other. Ensuring appropriate support is in place for all our staff through the provision of responsive

and proactive Workplace Health and Wellbeing services and infrastructures. To be respected by:

Demonstrating our commitment to living the values through ensuring appropriate behaviour and attitudes of all staff in line with the Bolton Employee and the Bolton Manager.

Not walking past poor behaviour ensuring that it is challenged proactively. Communicating with staff irrespective of position in a professional and courteous manner. Provision of appropriate learning opportunities to ensure staff have the appropriate skills to

fulfil their roles and demonstrate a ‘can do’ attitude. To be proud by:

Always promoting the excellent work of the Trust and upholding the values at all times. Being an ambassador for the organisation sharing what we do well and being involved in

continuous improvement. Taking pride in the provision of excellent learning and development, celebrating success

and promoting learning for all levels of staff. Promoting the organisation through positive recruitment strategies and working with our

local community to promote the NHS as ‘an employer of choice’.


WHAT DO OUR STAFF WANT AND HOW WILL WE RESPOND? During the early part of the year we implemented an engagement process to allow our staff to comment on our current workforce strategy and to let us know what we could do more of or what they felt was important for us to include in our updated strategy. Posters were put up in all areas across the hospital and community sites asking staff to “have their say”. In addition facilitated discussions led by the Senior Workforce Team and Divisional HR Business Managers were undertaken across the Trust. The response from all these discussions and collation of information from the posters was then themed and is extracted below: You said you would like:

To be provided with appropriate preparation and support in learning and developing your skills as team leaders and managers

To be provided with the opportunity to develop and deploy a range of flexible skills at whatever level you work at within the organisation

To understand the range of community and hospital based services and roles that exist to support improving the patient pathways for patients and your knowledge overall

Ongoing support to develop new and existing teams through appropriate learning and development interventions.

Improved leadership style and ability to take the organisation forward.

To achieve these things we will:

Support the development of leaders and managers to engage with staff in “The Bolton Way”

Improve the effectiveness of the organisation by supporting the development of all supervisors, managers and leaders

Ensure appraisal is taking place, audited and that there are clear links to performance management

Continue to promote a culture deploying a coaching approach to support improvement in staff performance and to support the realising of potential

Review all development programmes to ensure they continue to reflect all community and hospital knowledge and skills. It is important that awareness is raised amongst all staff in relation to what roles exist within both the community and hospital setting

Continue to improve workforce planning, communication and methodology Continue to improve recruitment processes based on competence and behaviours Implement a cost effective system to identify and support career development and

talent management at every level



Continue our facilitated staffing and specialty reviews to better plan our workforce in accordance with planned developments whilst looking at staffing benchmarks

Develop a co-ordinated workforce plan to ensure we understand the impact of service changes

Benchmark our staffing numbers and skill mix Support all staff through transition as a consequence of change

You said you would like:

Forward Planning for staffing on wards/departments More understanding of the role of Temporary Staffing Flexible working opportunities


Recruit staff on flexible working contracts where appropriate to support the appropriate deployment and utilisation of the contingent workforce

Continue to engage staff in looking at the workforce requirements of any area, encouraging improved team working and a more flexible approach

Review flexible contracting of staff to ensure we can respond to challenges within any area.

Support managers in workforce planning in the short, medium and longer term Ensure appropriate communication materials are developed across the organisation

to increase awareness of services that are available, how they can be accessed and what can be expected.


The right number of staff, in the right place, doing the right job with the right skills Focused customer service for patient care as a priority Better forward planning of staffing requirements The ability to change/transform/re-align staff along with services to be more able to react

to fluctuations in demand.



Staff to feel valued and to be praised when appropriate Everyone to be open and honest in their daily working lives Everyone to live the values of the organisation


Monitor and report on progress of the ongoing development of an engaging culture through the Best Employer group

Practically embed the values into all aspects of organisational life and measure their impact

Integrate the values into organisational processes such as recruitment, performance, communications , complaints and incidents

Improve the effectiveness of the organisation by supporting the development of managers and leaders

Provide a range of mechanisms to discover what matters to staff through a range of local and national surveys and engagement conversations

Provide a series of campaigns to support ongoing implementation of the values Formally measure the impact of implementing the values Integrate and spread “engagement” methodologies into individual and team

effectiveness approaches, BICS and communications Provide a range of services and interventions to support the development of associated

knowledge, skills and behaviours to staff at all levels of the Trust and across all services Continue to Increase levels of clinical engagement


More information on the role of the Workplace Health and Wellbeing (WHWB) Department (formally Occupational Health)

More Emotional Support for the current climate. Wellbeing initiatives to continue and new ones introduced to be provided across all sites.



Update the Workplace Health and Wellbeing pages of the Trust Intranet with clear and concise advice.

Develop and distribute written communication to describe services available to ensure all staff are aware.

Review our current approach to workplace health and wellbeing and develop and implement a health and wellbeing plan with contributions from our staff.

Further develop our mental wellbeing provision focusing on areas of emotional support and stress.

Continue our ongoing collaborative work, engaging with stakeholders to support a proactive approach to case management.

Ensure where possible workplace health and wellbeing initiatives are provided across all sites of the Trust, working with the local community to improve accessibility to facilities closer to work bases.


Better ways to get together as integrated team/departments Better use and quality of appraisals and simplification of documentation Training to reflect integrated nature of the Trust (community aspects) Clear objectives and priorities


Provide a clear career development framework that supports the development of staff knowledge and skills to enhance their competences and progress their careers based upon a quality appraisal

Provide clarity of expectations related to individual roles and responsibilities and an effective framework to monitor performance (appraisal)

Provide a comprehensive programme of learning and development for vocational and professional development


THE CONTEXT OF OUR PLANS EXTERNAL CONTEXT We welcome the broad objectives and principles in relation to the changes that are due to take place regarding the commissioning of education and the development of the healthcare workforce. In common with all other healthcare providers we have a clear interest in the affordable supply of high quality staff to meet the increasingly complex needs of our integrated services and patients, and those of our other partners in other sectors. In response to the developing market in healthcare services with the emergence of Safe and Sustainable as well as the pressure to reduce costs and improve efficiency, we will undoubtedly establish new service models in partnership with other NHS organisations as well as with other public sector and other providers. TRUST CONTEXT Vision and Values As has already been identified to drive to match the best integrated care organisations internationally for the quality and efficiency of our services by 2016 sets the direction of travel and outputs required from this strategy. In addition we want to be known for the safety, effectiveness and compassion of the care we provide. The delivery of our vision is underpinned by our Core Values. Our values were developed during 2011 and launched in April 2012 following extensive consultation with our staff, patients and other stakeholders. They set the standards to which we aspire as an organisation both in our service to patients and in our conduct towards each other. We are therefore committed to ensuring that the values and the behaviours they identify are a core component of all areas of this strategy. Our values are illustrated over the page.



Governance

A core component for ensuring the quality of our workforce and achieving our vision of safe, effective and compassionate care is the assurance we must have and must, in turn, be able to provide to our regulators working on behalf of the public as to the safety of our working practices. Five areas of policy which are central to providing this assurance in relation to our workforce are:-

Safe recruitment and induction practice. Compliance with mandatory training requirements. Staff being able to raise concerns (whistle-blowing) Effective systems of feedback Revalidation of medical and dental staff.

We will seek assurance of our progress in these areas through programmes of internal audit and self assessment against the quality standards set by the Care Quality Commission (CQC) and Monitor. In addition we will seek to improve policy and practice in ways which enable improved accreditation by external assessments such as the NHS Litigation Authority (NHSLA). At the same time the Board must be assured that changes in working practices or workforce numbers can be achieved in a manner which does not compromise clinical outcomes, patient experience and patient safety as well as staff health and wellbeing. There is therefore a series of important links and areas of joint endeavour with the quality strategy which is currently being developed. Workforce Planning In engaging with the emerging new arrangements for the commissioning of education and system wide workforce planning, we need to ensure we continue to take steps to improve efficiencies of our services and the consequent reductions in cost. We have many workforce challenges that we can be address through good workforce planning, these challenges include:

The need for increased flexibility and versatility in the workforce The need to plan for surges in activity and demand The need to respond to requirements for 7 day working

Partnership and Engagement Staff engagement is crucial to our future direction and we have been working towards an engaging culture throughout the organisation. Transformational change requires a shift in the culture of an organisation. Culture can be seen by some as hard to quantify and its importance therefore dismissed. Culture change requires personal change and this adds to the uncertainty for many managers and leaders. To achieve the business benefit required it is essential that appropriate behaviour and attitude is demonstrated from the top – only by doing this will the tangible benefits be realised. An engaging culture achieves results and these can be seen both quantitatively through the staff survey and other key workforce indicators as well as qualitatively through improvements in team


working and staff stories. Integration has provided us with the ideal platform from which to blend the positive experiences of our staff from a number of cultures and bring them together to create an even better culture for the organisation.

There is no one single blue print for staff engagement, it has been essential that the approach is moulded to the organisation and its current infrastructure of the Bolton Improving Care System (BICS). BICS is about engagement of those closest to the line being involved in improvement and directly influences outcomes and removing waste. An engaging culture fully complements this approach, building on the respect for people pillar and adding to it by developing a way of leading and managing, deploying engaging skills that embrace BICS and live the values of the organisation day to day. Staff who work in this consistent environment where ‘the Bolton Way’ is their experience everyday are increasingly motivated, feel valued and appreciated. As a direct consequence they deliver consistently and passionately doing the best they can and thus applying continued discretionary effort to their role. The importance of staff engagement is globally recognised and within the NHS it has been significantly associated with the correlation between patient and staff experiences, the need for continuous improvement and quality and safety outcomes. Engagement is not a new phenomenon to the organisation, we have been moving towards cultural transformation embracing improvement and engagement for the last five years. We intend to continue enjoying good strong partnership working within the organisation by working with staff and staff representatives in all areas of the Trust. There are significant benefits that can be achieved for both staff and the organisation in working in partnership. Our Staff Side colleagues are involved in decision-making at all levels across the organisation. The Staff Side Chair is a member of the Executive Board and our Workforce Committee, alongside a number of other corporate meetings. Other Staff Side representatives are members of various meetings to ensure they are fully engaged in decisions and future planning. Our Joint Negotiation and Consultative Committee (JNCC) meets on a monthly basis, and discusses and debates strategic issues and their impact on the workforce. Constructive challenge and debate is seen as healthy, and is encouraged by all members. The Director of Workforce and Organisational Development ensures a regular review of the meeting to ensure it continues to meet members’ expectations. Following the integration in 2011 we developed a new constitution which sets out key principles and behaviours for partnership working and also to clarify time-off to facilitate maximum Staff Side engagement and input. In the development and review of newly integrated employment policies, direct involvement of Staff Side is vital and we have worked with our representatives across operational areas to ensure we have this input. With the changing landscape of the NHS, significant change is inevitable and will require strong engagement with Staff Side in management of challenging workforce issues. Investment in this relationship is crucial to ensure engagement is sustained and improved. Equality and Diversity

Equality and diversity are at the heart of the NHS strategy. Investing in the NHS workforce allows us to deliver a better service and improve patient care in the NHS. It is our belief that everyone can participate and be given the opportunity to realise their potential. We recognise and value


difference and aim to create a working culture and practices that recognise respect, value and harness difference for the benefit of the organisation and the individual, including patients.

We are committed to providing a high quality, accessible and responsive service, provided by staff who reflect the local community, putting the patient at the heart of everything we do. Over the previous year we have delivered a much improved service to both staff and patients in ensuring equality and diversity of treatment.

Some of the key achievements have included:

Annual employment monitoring which has been developed and is now embedded into the organisation’s agenda, Compliance with the Equality Act.

Obtaining the Disability Two Ticks Symbol, Development and maintenance of a system which enables equality in access to training and development

An Equality Impact Assessment process has been embedded into the organisation and is utilised for all changes in organisational policy and service.

Some of the future key areas for consideration are:

Obtaining clarity in the data held on staff to ensure that this identifies a true representation of the workforce

Undertaking proactive activities to promote the different equality strands across the organisation

To look at the equality ‘gaps’ within the organisation and to consider positive action in these areas.

People Management Through continuous management development opportunities we will ensure that anyone in a supervisory or management role receives appropriate training and development to support them in their role and they reflect the latest people management practices that are evidence based. Building workforce capacity and capability improves our efficiency through a performance culture that supports and develops our staff, allowing everyone to share in our objectives. The workforce agenda and integration of other services and organisations has presented many diverse challenges and opportunities, which has required us to review the workforce contribution and embark on our innovative journey. We have actively engaged with staff and staff side colleagues across the Trust in planning and organising our workforce services, this engagement has been extremely helpful in identifying, developing and resourcing priority activities. As such, the Workforce Directorate is leading a range of people management programmes and initiatives to enable and empower our staff to meet the challenges and opportunities we face. We are building capacity and capabilities by:

The development of a range of new Leadership and Management programmes from Medical Leadership to Team Leader levels to specifically support organisational change and effectiveness

Ensuring Coaching skills are at the heart of all leadership and management development interventions


Support line managers on the consistent and fair management of performance within their teams

Review and promote the management induction policy and handbook for all new managers/supervisors

Developing and publishing key workforce metrics and measurement information and improving information/data intelligence, trend analysis and benchmarking

Continual review of workforce capacity and relationships and building programmes to support working differently

Social Responsibility It is important that we continue to attract staff from diverse backgrounds and we are supporting this by improving our already successful links with external organisations such as Jobcentre Plus and Bolton Metro. We also use our engagement with key stakeholders to raise our profile as a potential employer. We support the local council who target long term unemployed/disabled people and assist in preparing them to return to the workforce and help them to secure employment. In addition, we participate in joint recruitment events providing advice and guidance to disabled/long term unemployed people.

We are keen to continue our support to Bolton Council in the movement into employment of residents from deprived areas, and in particular those in receipt of benefit. We see that by maximising employment chances for everyone and thereby seeking to eliminate social exclusion, we will bring economic advantage, new investment and ultimately improved health and well being to the local community. We are working closely with local and regional groups in targeting recruitment exercises to the unemployed, disabled, ethnic groups and refugees wherever possible. So far, a number of people have secured employment with us, who would not have applied without our active involvement. Our recruitment marketing plan actively engages the local communities. Job shops/recruitment fairs within community centres have been organised and are expected to increase throughout the coming years. Transform processes that promote effective working and use of technology Working with the BICS team, we will continue to engage the workforce in the re-design of pathways and processes to ultimately provide better quality care for our patients. Staff have the creative and innovative solutions to how things could be improved. We need to continue creating the culture where this is encouraged and staff competencies and confidence is developed to facilitate them in embracing changes that affect them. We are committed to realising the benefits arising from e-technology with the implementation and roll out of a number of systems to include, SimpleSAF, making it easier for managers to make changes in relation to their team, e-rostering, based on sound rostering practice, directly interfacing with the payroll system, and the design of many more e-learning packages to enable staff to keep up to date without onerous time commitments. In relation to information technology, our vision is to ensure that all staff are equipped with the necessary knowledge and skills to confidently utilise information technology, both within their role and in relation to their own personal development. It is essential that the workforce has access to the most appropriate systems to enable each individual to undertake their role in the best way.


Robust performance development review and support Our staff want to do a good job and having a robust framework which is clear on what is expected of them, monitors performance against those expectations and rewards, whilst recognising that excellence and development is key to the motivation of our staff. It directly correlates with our strategic aim of providing high quality care and being able to treat more patients more effectively, which in turn leads to better morale and staff experiencing greater job satisfaction through performing more satisfying roles. As the research demonstrates, there is a strong correlation with staff appraisal and lower patient mortality. A good quality appraisal will ensure that our staff receive feedback on their performance and behaviour with a clear development plan agreed with them to support their motivation and engagement levels, future development and career aspirations. The Board of Directors have a target of 80% compliance with all staff having an annual appraisal, this target will continue to be monitored weekly to ensure that appraisals are taking place. In addition, we also carry out audits to ensure not only the target is met, but also that the appraisal is a high quality experience for those being appraised. The Appraisal documentation has been reviewed in consultation with staff groups and now contains the Trust core values against which staff can be assessed to ensure their behaviours reflect those required in a high quality healthcare provider. Effective Learning and Development

We continue to enjoy an excellent reputation for the provision of learning and development, evidenced through the staff survey. Our Vision and Strategy to match the best integrated care organisations internationally, has made a commitment to provide the organisational development and learning that is central to improving patient care and supporting staff to grow, develop and realise their potential. We will begin to incorporate the principles of Education Governance, which means:-

the corporate management and governance of education and learning is formalised within our organisational structures, with Board-level responsibility and accountability for education

Education Governance has the same priority as Clinical Governance There are open, transparent, accessible, clear and equitable opportunities for the whole

Workforce There is a multi-professional governance approach, with enhanced learning leadership,

enabling best practice to be shared across all healthcare disciplines and across all levels of staff involved in the delivery of health services

The challenges of delivering better, faster, safer care and services in a constantly changing healthcare environment requires a workforce that is capable, responsive and committed to continuous learning and development. This involves our staff at all levels being equipped with the right knowledge, skills and behaviours for the roles they undertake and to make contributions towards continuous improvement. Achieving the vision begins with providing clear information and processes that enable our staff to identify and meet their learning and development needs, supporting individual and organisational effectiveness, which in healthcare organisations can be complex. By using local and national best practice methodologies and frameworks, we have sought to design a simple


framework to identify learning and development needs and activities. We want our staff to feel valued for the contribution they make towards improving the effectiveness of the organisation. The diagram below illustrates the continuous cycle of learning and organisational development, providing our own definitions of what they mean at the Trust.

Diagram 1 – Organisational Development/Learning Cycle

ORGANISATIONAL DEVELOPMENT

Is a term used to describe the approach that we will take to enable our staff to engage in making a contribution

towards continuouslyimproving the quality of patient care and services.

It concerns understanding and changing our culture, creating an environment where staff are inspired, motivated

and encouraged to get involvedin continuous improvement activity. It is inter-dependant with service

improvement, good management, leadershipand lifelong learning

LEARNING

Is the term used to describe the process by which knowledge,skills and qualifications essential for the delivery of safe high quality

care and services can be obtained.

The purpose of the learning strategy is to be flexible enough to meetthe needs of both individual staff and the Trust in order to fulfil

individual potential and the healthcare challenges.Learning activities can be both formal and informal and central to

developing vocational/occupationaland professional competence.

We want to ensure that all our staff are clear about their development needs and can engage fully in the process of identifying their own needs, undertaking activities and evaluating their effectiveness. The delivery of timely and effective learning and development begins with providing clear information, structure and processes that enable both staff and managers to identify and meet learning and development needs. In healthcare organisations this can be complex and there is a need to balance individual and organisational development needs within available resources. The basic building blocks for supporting good people management and learning are associated with the appraisal and personal development planning process. Our practice is guided by the Appraisal and Personal Development Planning and the Study Leave policies which we need to ensure are consistently applied, ensuring equality of access to learning and development for all staff.

The Annual Development Cycle We have a development cycle in place, which integrates the appraisal and personal development review process with the annual business planning cycle, which is guided by policy and training for appraisers and appraisees. Individual identified development needs are written into an individual Personal Development Plan. Departmental plans are aggregated into broad


departmental and divisional/directorate plans in order to identify the priority corporate learning and development activities. In addition, an analysis of our business plan is undertaken to identify priority corporate learning and development needs, to ensure that there is a balance between individual requirements and organisational effectiveness. We want to ensure that all our staff understand the development cycle, both in terms of their own development and that of the organisation ensuring access to a quality annual appraisal/performance review. The annual development cycle process is illustrated in diagram 2. Diagram 2 – Annual Development Planning Cycle

Identification of L&D needs(Job descriptions & post outlines,

corporate business, work force and divisional plans)

Development of Individual and

Corporate L & D plans

Access to a range ofLearning

And DevelopmentActivities

Review and EvaluationOf Effectiveness and investment

Identification of Learning and Development Needs We want to ensure that all of our staff are clear about how to evaluate the effectiveness of their learning and development in relation to their own personal development and the improvements that they can make towards patient care and services that we provide. The NHS Knowledge and skills framework (NHS KSF) provides a comprehensive description of the foundation knowledge and skills that NHS staff need to apply to their work. It is associated with all aspects of development from induction to career and pay progression and encompasses the process of


continuous development review. To aid the identification of individual learning and development needs a development framework has been designed to act as guide for staff and managers. Bolton Development Framework

We have produced our own career development framework which provides a clear developmental pathway or skills escalator of career progression and the associated knowledge, skills and qualifications for all levels of staff. The framework is illustrated at Diagram 3. The use of the framework in the context of organisational development and learning provides a flexible guide for our staff and managers to focus upon the knowledge, skills and competencies required for existing and developing roles in a constantly changing healthcare context. Diagram 4 shows how the guide can be applied at all levels within the organisation. The development levels are included in our framework in order to determine the minimum level of knowledge and skills that individual staff members are required to attain in order to ensure quality, safety and improvement for patients and in the workplace. The inclusion of the levels reflects the Knowledge Skills Framework (KSF) and demonstrates the flexibility and range of development aligned to role re-design and career progression. Diagram 3 –Bolton Development Framework Pay Band Level

KSF Dimensions

Ma

nda

tory

Tra

inin

g

Bolto

n Im

pro

ving

Ca

re S

yste

m (

BIC

S)

Info

rma

tion

Tec

hno

log

y Tr

ain

ing

Co

ntiu

ing

Vo

ca

tiona

l/Pr

ofe

ssio

nal

Ma

nag

em

ent

and

Le

ad

ers

hip

Qualifications linked to bands

9

All core & identified specifics

Leadership/Management Masters/Doctorate

8


Leadership/management Masters

7


Further professional degree Masters level study

6


Professional degree Masters level study

5


Professional Diploma/degree Post Grad degree

4


Foundation Degree

3


NVQ Level 3 Skills for life

2


NVQ Level 2 Skills for life

1

Core

Key skills/basic skills KSF Core Curriculum

Development (Escalator) Levels Level 1

Awareness and understanding (induction and information)

Level 2

Competent practice (basic knowledge and skills training)

Level 3

Specialist knowledge and skills, leadership capabilities

Level 4

Expert knowledge and skills, master teacher


Diagram 4 – Development activities

Pay Band Levels

KSF Dimensions

Development Activities

Associated Qualifications

Mandatory Training Bolton Improving Care System (BICS)

Information Technology

Training

Initial and Continuing vocational/ Professional

development

Management and leadership

development

1-9

Identification of core and

specific dimensions associated

with job description

and KSF post outline

Identification of training needs

associated with the role

As per MT Policy frequency and

level

Identification of

level of development

associated with role and/or

improvement involvement and

career development

Identification

of level of development

associated with role and

career development

Identification



career development

Identification



career development

Identification of

the most appropriate method of

development

Development (Escalator) Levels

Level 1 Awareness and understanding (induction and information) Core knowledge skills and behaviours

Core and specific KSF Core mandatory and IT knowledge and skills Key skills for healthcare role Basic care and service skills Basic awareness of BICS

Level 2 Competent practice (basic knowledge and skills training) Specific and specialised knowledge, skills and behaviours

Core and specific KSF Core mandatory and IT knowledge and skills Occupational knowledge and skills Continuing professional knowledge and skills Mentoring and assessor competence BICS Practitioner

Level 3 Specialist knowledge and skills, leadership capabilities Leadership knowledge, skills and behaviours

Core and specific KSF Core mandatory and IT knowledge and skills Supervisory and management skills Leadership qualities development BICS Leadership

Level 4 Expert knowledge and skills, master teacher Expert, executive knowledge, skills and behaviours

Core and specific KSF Core mandatory and IT knowledge and skills Supervisory and management skills Leadership qualities development Expert knowledge and skills Succession planning Talent management BICS Expertise


Within the framework several strands of learning and development activity have been identified that represent essential areas of development associated with the provision of healthcare. The framework provides a practical method of applying the NHS KSF and a road map for discussion and identification of development needs in relation to role effectiveness and future development aspirations. Our vision for each of the strands is:

Mandatory Training We want to ensure the delivery of safe, high quality care, through access to and continuous updating of mandatory and essential skills. We have a well established mandatory training team that provides a comprehensive range of training programmes and services in dedicated training centres as well as directly in the workplace. We have introduced E- Learning for aspects of Mandatory training to support services by ensuring staff are able to fulfil mandatory training requirements in the most effective way in terms of time and quality of learning experience. We will continue to review the programme in relation to national and local drivers and seek to ensure that access to training is as effective as possible, utilising new learning technologies and strategies. Bolton Improving Care System (BICS) Our commitment to continuous improvement continues with renewed energy and focus. The Lean Academy has been extremely successful in the delivery of programmes to develop staff at all levels in understanding our lean journey, numerous processes and techniques alongside development on lean leadership. All of our learning and development programmes continue to ensure that the message of continuous improvement and engagement are consistent. Information Technology With the emergence of a new refreshed IT strategy, we will continue to ensure that all staff are equipped with the necessary knowledge and skills to use IT with confidence within their day to day work and also as part of their individual personal development. E technology is the future with increasing use of mobile media to support immediate access to essential information and also to support learning in a more timely and effective way. We need to ensure the availability and access to technology in line with increased use of this medium. Workforce Competency Development We aim to enable all staff to continuously develop the necessary knowledge, skills and behaviours in a constantly changing healthcare environment and to expand our inter-professional/vocational learning agenda. We have a well established service to support the development of workforce competency at both vocational and professional levels with the provision of a range of internal programmes and advice and guidance services. In 2012 an internal Medical Leadership and a New Consultant development programme was designed and delivered to compliment the portfolio of Leadership and Management programmes currently offered. We have developed a number of partnership arrangements with a number of key stakeholders including; NHS North West, Further and Higher Education partnerships (Bolton University and, Bolton Community College and all Greater Manchester Universities). We are an accredited centre for the delivery of a range of leadership & management programmes and National Vocational Qualifications. We liaise closely with the local universities on pre-registration programmes and we co-ordinate the allocation of Higher Education modules.


ACHIEVING VALUED RESPECTED AND PROUD FOR OUR STAFF OUR CORE WORKSTREAMS

WORKSTREAM ONE - EFFECTIVE LEADERSHIP, ENGAGEMENT AND ACCOUNTABILITY We have a clear sense of direction and purpose, leadership is crucial in defining, reinforcing and maintaining that direction. In order for this to happen, we must have the right people, with the right leadership and management skills to support achievement of the strategic goals and form part of its commitment to ensuring high quality care for all.

An inspired, skilled and efficient leadership workforce is critical in order for us to achieve our goals and deliver the best possible care to our patients and service users. Leadership is no longer considered as the realm of the most senior. We require leaders at every level, to share accountability and develop leadership throughout the organisation to foster greater degrees of responsibility, innovations, problem solving and coaching capability. Leaders will need to have the skills to motivate staff to enable extra discretionary effort in the service. Linking organisational leadership to the bottom line through effective leadership at every level is a critical task for all of our leaders. To achieve this, we must:-

Embed systems and processes for developing leadership capability throughout the Trust, by

making the development of our staff everyone’s responsibility and putting in place enabling mechanisms to build the skills and capabilities necessary for leaders to lead adaptive and highly productive teams.

Ensure Medical Leadership development and engagement is a priority as our Medical Leaders are central to transforming services.

Build and consolidate a high performing and inspirational leadership culture that embraces

change and encourages innovation.

Remove structural barriers such as inconsistent practices, silo working and obstructive bureaucracy which hinder the building of a culture of improvement across the Trust.

As much as good leadership is critical to success, exemplar management is also required. Leadership and management are similar and different; job roles within the Trust may combine leadership and management equally, or clearly have the features of one more than the other. To enable our managers to become better leaders, we will continue to build on the use of the Leadership Management Style Questionnaire (LMSQ) and the standard of the ‘Bolton Manager’ to ensure that there is a recognised and consistent approach to the way we lead and manage our staff. This is also reflected in the Trust Values, which are a key component to organisational development, not only in fostering high performance but also in shaping organisational transformation and culture. All our leaders and managers should be able to demonstrate increased return on investment in terms of cost savings, improved quality, higher productivity and improved patient and service user satisfaction as well as increased employee engagement.


A detailed plan of how we will achieve effective leadership, engagement and accountability is contained in a project plan (A3), which will also be used to monitor our progress against the set objectives. The headlines from this plan are attached in Appendix One. WORKSTREAM TWO - VERSATILITY OF THE WORKFORCE- TO REALIGN AND TRANSFORM AS SERVICES CHANGE As a provider of NHS services, we are operating in an ever changing environment, with health care services now being commissioned differently within the new NHS infrastructure. There is more emphasis on network collaborations for more specialised services. There is a drive to provide more services out in the community of the population we serve. Urgent care continues to be a key priority so that patients that need our help urgently can access our services whether this is most appropriate in a GP surgery or in an Accident and Emergency department. One of the key reasons for Integration in 2011 was to bring together two excellent, high achieving provider organisations with a view to providing seamless quality services for our population across integrated acute and community pathways in a more efficient way with no organisational barriers to overcome. As a result of this context it is crucial that we can respond to the needs of our population and provide the health care services that are required. As these needs change we may develop new services, we may change or adapt existing services or we may choose to stop providing certain services that are no longer required of us. It is essential that we can support our workforce to be as versatile as possible so that as services change we can easily re-shape and adapt to ensure we are fit for purpose in an increasingly competitive environment. Change, whether it is big or small, can be daunting for everybody. Ensuring we have the right processes in place which ensure equity and fairness and provide the right levels of support for every individual who is undergoing change is critical to the success any change programme. In order for us to provide top class, quality services it is important that we plan our workforce in a way that considers our links with education providers to ensure we help train students so that they graduate into the professionals we need. We also need to forward plan and forecast service development in a timely way to ensure we address the workforce requirements, whether this is planned recruitment or that we need prepare the team for any skills development required or even looking at new roles. The implementation of more e-learning packages is helping us with many aspects of our mandatory learning requirements. Staffing benchmarks are an important tool for us to use to ensure we understand and have confidence that the right numbers and skill mix of staff is in place so that our teams are properly resourced to provide the best levels of care possible. When we consider the versatility of the workforce, this goes beyond skill and technical competence. Whilst this is critical for every member of the team, equally important is the behaviour we all display when dealing with our patients and our colleagues. Our core values include the behaviours we believe fundamentally support the living of our values every day. It is vital that these values and behaviours inform all of our workforce processes so that all our teams are fully engaged with our mission. This will include recruitment, how we interact with our patients and colleagues, managing performance and leadership behaviour.


A detailed plan of how we will achieve versatility of the workforce - to realign and transform as services change is contained in a project plan (A3), which will also be used to monitor our progress against the set objectives. The headlines from this plan are attached in Appendix One. WORKSTREAM THREE - FLEXIBLE WORKING – MATCHING CAPACITY WITH DEMAND We provide a variety of diverse services across hospital and community settings. Many of our services are required overnight and at the weekend. Many of our services also have seasonal trends, meaning that at certain times of the year some services are much busier than at other times of the year, this can be different for different services, and for example paediatrics and older people have their peaks at very different times of the year. It is important that we fully understand the workforce implications of our variable demand, service by service, so that we have the right staff on duty at the time we most need them. We need to understand this variability in two ways, in relation to the shift patterns worked across the week, and whether we need more staff working in winter months than in the summer, or it could be a combination of both. In relation to urgent care across our services we need to ensure that we provide equally safe services regardless of when a patient accesses our systems, so the care that we deliver is standard whether it is a Tuesday or a Sunday. As a public service we also have public expectations that health care should be accessed when it is convenient for people, which can often be outside traditional working hours. This is particularly relevant for elective care with the expectation that routine appointments should be available to the public outside of normal working hours. Both these issues are driving the need to provide more of our services across seven days. This for some of our workforce will represent a fundamental change to the way we work now, for others the change is minimal because rotational shift patterns have been in place for some time. To ensure that we continue to meet changing needs of patients and of our commissioners; we need to develop more innovative roles that are flexible and responsive to change. We will need to work with our temporary workforce to develop capacity that can respond to fluctuations in demand. We will work with staff to examine flexible working options that work best for all stakeholders whilst maintaining consistent service delivery. Increasing the productivity and efficiency of our staff is essential in order to maximise resources and improve the quality and safety of patient care. Working with Divisions and Directorates we need to help staff to work in different ways, which achieve productivity efficiencies. A range of productivity measurements will be used including managing agency staff use and costs as well as unit labour costs (one method is a ratio of activity and staff costs). In order for us to better match the capacity of our workforce with the demand of our patients, whether that is across the week or across the year we can make changes to the following:

Flexible contracts

Annualised hours in place

Medical job plans to match seasonal peaks


A key part of our workforce to help us quickly adapt to changes in demand are the temporary staff. Effective deployment of this staff group is essential to provide responsive and safe services in the most cost effective way. A robust induction programme and regular mandatory training for our temporary staff is essential to ensure staff are equipped with the rights skills and knowledge to undertake the role. Effective roster management to ensure temporary staff are only used in the right circumstances is also key to ensuring that our workforce is efficiently managed. We have seen reductions in bank and agency expenditure due to much tighter controls being implemented. There is still further work to do in this area, particularly relating to how we staff additional wards when we need them. We will need to examine closely, strategies for developing a more flexible workforce, including the potential expansion of the temporary staffing system, to promote further workforce flexibility. This will allow us to effectively respond to fluctuations in activity in relation to workforce availability and flexibility. The changing demographics of the workforce and increased competition for highly skilled healthcare staff will require new and more flexible ways of working. As we have already highlighted we will need to find innovative solutions in how and where our services are delivered whilst maximising the competence of our existing staff. This will include challenging historical professional boundaries to achieve greater flexibility, which is a core component of our Workforce Strategy over the next five years. A detailed plan of how we will achieve versatility of the workforce - to realign and transform as services change is contained in a project plan (A3), which will also be used to monitor our progress against the set objectives. The headlines for this plan are outlined in Appendix One.

WORKSTREAM FOUR - EMBED THE VALUES INTO THE WAY WE DO ALL THINGS The requirement for a fully engaged, competent and flexible workforce to meet the radical changes facing the NHS has never been more important. Staff engagement describes what happens when people think and act in a positive way about the work they do, the people they work with and the organisation that they work in. To achieve this, we have been steadily working towards transforming the culture of the organisation in terms of the way we involve and listen to our staff through the use of a variety of approaches such as BICS, staff engagement “conversations” and staff surveys. During 2010 and 2011 over 700 staff took part in a series of Big and Small Conversations about what mattered to them at work. The conversations identified a number of key priorities which were as follows:

A clear set of values that outline standards of behaviour and attitude towards patients and each other

A review of the appraisal process

A review of leadership and management and team effectiveness training

A review of workforce health and wellbeing, recognition and reward

A review of staffing levels in clinical areas

A review of communication methods


All of the initial work related to the key priorities listed above has been completed and work will continue to make ongoing improvements that will be led and monitored by our Best Employer Group which is made up of representatives from all divisions and directorates. The core values referred to earlier describe the “Bolton Way” and from each of the values a simplified set of behaviours and attitudes have been derived to aid practical use of the values in everyday working life and these are described as the Bolton Employee and the Bolton Manager.

The Bolton Employee

Is patient focused at all times Is focused on continuous improvement Is flexible and adaptable Is friendly Is considerate Is honest Is positive and enthusiastic Is respectful Is reliable Is willing to get involved/engaged Is team and colleague focused

The Bolton Manager

Is patient and staff focused at all times Is focused on continuously improving, bring BICS into day to day activity Is supportive Is engaging Is approachable Is fair and consistent Is encouraging and inspirational Is skilled at recognising and appreciating staff Is visible Is a good listener and communicator Is skilled at challenging poor behaviour and performance Is accountable

Through the use of the appraisal process for all staff and a specially designed questionnaire for managers known as the Leadership and Management Style Questionnaire (LMSQ) we will be able to discuss and measure the extent to which staff at all levels of the organisation are living the valves and provide support and training for identified areas of development. Our approach to engaging with staff using engagement methodologies has become an award winning way in which the Trust wants to continue to engage and involve staff in order to create an organisation that has the best reputation to be cared for as a patient and to work in as an employee. Our aim is to embed the core values into all HR policies and process to ensure that we are aligning our expectations in respect of behaviour into how we manage and lead alongside how we challenge poor performance. We are embedding the values into recruitment and selection processes, appraisal and performance management.


A detailed plan of how we will embed the values into the way we do all things is contained in a project plan (A3), which will also be used to monitor our progress against the set objectives. The headlines for this plan are outlined in Appendix One. WORKSTREAM FIVE - CARING FOR THE HEALTH AND WELLBEING OF STAFF The national vision is for the full breadth of NHS staff health and wellbeing needs to be met as part of an organisational and system wide approach to improving health in the workplace. We help maintain and improve the health of our staff at work for the benefit of the patients they treat and the organisation as a whole. Our approach is holistic and provides staff with an efficient and effective “wrap around” service which covers both physical and mental wellbeing. Protecting and promoting the health of our staff is backed by strong leadership and visible support at Board level. Our Workplace Health and Wellbeing (WHWB) service is located in a modern fit for purpose building which enables us to increase capacity to meet increasing demand. Our services to support staff health and wellbeing are wide ranging the following is just a selection of the health and wellbeing initiatives and interventions we provide: Staff health clinics - the aim of the clinics is to improve staff health and wellbeing, to increase access to health services and to reduce sickness absence rates. Health Trainers offer health checks to all staff, including; blood pressure and pulse readings, waist circumference and BMI, advice on diet, exercise and general lifestyle and signposting to both internal and external agencies for further support and advice. Both Rite Weight and Stop Smoking service are also available on a weekly basis to offer 1:1 support and advice on losing weight and stopping smoking. The clinics take place every weekly and run primarily on a drop-in basis but appointments are made available where necessary. The clinics are held in the Workplace Health and Wellbeing Department, however in order to allow more clinical staff to access the service some sessions are being held in wards and departments and community settings. Mental wellbeing drop-in - clinics are held twice a week and consist of a 10-minute session with a Mental Health Practitioner who provides advice and information. This has improved mental well-being preventing mental health problems and resulting in a reduction in the numbers of staff going off sick and increasing the number who return to work quicker. It is the intention that the advice and information given at the mental well-being drop-in clinics will also be available on the intranet for staff that are unable to attend the drop-in clinics. Monthly business meeting with HR Advisors and Mental Well-being Specialist are also held to discuss mental health issues relating to presenteeism and sickness and absence within departments and directorates. At these meetings possible intervention, support and advice is discussed including when to complete a Stress Risk assessment. Gym memberships and Zumba classes – We organise and offer a subsidised rate for staff to the on-site gym which includes free attendance at keep fit and Zumba Classes. Staff are also able to


join in individual classes again at a reduced nominal fee. We feel that by supporting the physical health of our staff in addition to the mental health we are offering something for everyone. In addition to the above we also offer the following:

Fast track physiotherapy Healthy walks Healthy “fruit and veg” Van Counselling Free flu vaccinations Stress risk assessments and follow up Pre employment checks Workplace assessments

To ensure we are at the forefront of new ways of working we regularly take part in national audits for example; Occupational Health Patient Satisfaction Survey, National Audit of Record Keeping Standards and National Audit of Back Pain Management. Participation in these audits is also evidence that the department complies with the standards set out for Safe and Effective Quality Occupational Health Service (SEQOHS) accreditation. Health promotion is key in supporting staff to stay well. As we train our staff to support patients in areas such as smoking cessation, weight management, alcohol and cancer awareness, healthy eating and getting active, we are giving our staff the tools they may also need for themselves. In addition if we can then support them by provision of our own services or by signposting to external support services we may prevent future absence from work. To support us in this new area of work we are working alongside a local health improvement specialist who in addition to his role in the Health Promoting Hospital accreditation supports us to make health improvements and put personal health a priority for our staff and their families. A recent successful achievement is improved food and nutrition provision for staff and patients. Food sold on hospital premises includes traffic light labelling and calorie counting in addition to the removal of unhealthy snack food and drink products. The WHWB team have and continue to lead in successful campaigns to vaccinate staff against seasonal flu. We are currently undertaking a review in order that we can appropriately prepare and improve on uptake for future campaigns, resulting in greater protection for both staff, patients and their families. We support staff to achieve the highest level of performance, contributing to operational efficiency through dedicated work with staff and managers. We have an established workplace health and wellbeing framework within which our staff feel engaged, supported and provided with opportunities for health and wellbeing improvement. We support staff to remain in work and/or return to work quicker where their very precious skills, experience and knowledge are needed and much appreciated. A detailed plan of how we will care for the health and wellbeing of staff is contained in a project plan (A3), which will also be used to monitor our progress against the set objectives. The headlines for this plan are outlined in Appendix One.


MEASURING OUR SUCCESS It is essential that we measure the success of our workforce strategy and we can do this in many forums but the principles of provision will be to support the devolution whilst providing assurance. The purpose will be to provide evidence to ensure that work being undertaken in relation to the implementation of the strategy is effective and adding value to the patient and staff experience.

We will measure the implementation of the strategy via the following approaches:

Continuous monitoring of the achievement of the milestones highlighted in the milestone plan by the Workforce Directorate Board, the Workforce Committee and the relevant reporting working groups which all play a part in the delivery of the strategy.

We will continue to benchmark ourselves using key quantitative workforce data and correlate this with operational, finance and quality data.

Regularly review progress with our JNCC. Quarterly staff temperature checks. Leadership Management Styles Questionnaire (LMSQ) analysis and theming.

NEXT STEPS The delivery of the key milestones of this strategy is set out in the Key Milestone Plan at Appendix One, and it identifies our key areas for delivery for 2012 -13. This will rely on strong performance management, accessible and reliable information, supported by Workforce Transformation and Organisational Development. In addition it continues to rely on the embedding of systems of delivery that support and engage clinicians’ in improving the quality of services’ interactive staff feedback and ensuring that we find the vest evidence externally and undertake research to set the benchmark for others to follow. Information from the engagement events has been integrated into our strategy to ensure that we continue to respond to the key issues for our staff. Continued engagement with patients, carers and families, alongside our governors and members is essential to ensure we continue to respond to changing needs and expectations.

REPORTING PROGRESS An annual report on progress will be provided to the Board of Directors with more regular monitoring via the Workforce Committee.

REVIEW OF THE STRATEGY This strategy will be reviewed by April 2013 with the Director of Workforce and Organisational Development initiating the review to ensure it remains fit for purpose.


CONCLUSION The Trust has continued to make progress on transforming its culture, developing and involving our workforce but there is still much to do in creating a ‘Great Place to Work’. Work will continue on the development of effective workforce practice and processes that underpin best care for better health for our patients. Working with our members, governor and other partners is essential to build on engagement both internally and externally, building on our social responsibilities and making a valuable contribution to the Bolton Family.

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www.pwc.co.uk

Indicative InternalAudit Plan 2013/14

Final

Bolton NHSFoundation Trust

August 2013

PwC Contents

Contents1. Introduction and approach 1

2. Audit Universe 3

3. Risk assessment 4

4. Indicative Audit Plan and Timings 8

Appendix 1: List of Interviewees 12

Appendix 2: Key performance indicators 13

Distribution List:

Simon Worthington Director of Finance

Members of the Audit Committee

This document has been prepared only for Bolton NHS Foundation Trust (“theTrust”) and solely for the purpose and on the terms agreed with the Trust.

Internal Audit Plan forBolton NHS Foundation Trust PwC 1

IntroductionThis document sets out the risk assessment and our internal audit plan for the Bolton NHS Foundation Trust(“the Trust”). Our approach to developing the audit plan for 2013/14 is set out below.

Defining the Audit UniverseWe have identified the auditable units within the Trust on its organisational structure, risk profile, ourcumulative knowledge and the results of discussions with management. Any processes which run across anumber of different units within the organisation and which can be audited once are identified as a separateauditable unit.

We are aware that the Trust is currently reviewing the Board Assurance Framework (BAF). Once this isexercise is complete we will revisit the plan to ensure that the key risks identified on the BAF are linked to theInternal Audit plan. This will show the Audit Committee how our work links to the Trust’s key objectives andrisks.

Our work to dateThe following steps have been undertaken to develop the Internal Audit plan for the 2013/14 financial year:

Meetings with some of the Non Executive Directors, and member of the management team from acrossthe Trust to discuss objectives, risks and priorities within their specific operational areas and the widerTrust (Refer to Appendix 1 for a list of interviewees);obtaining various reports and the Trust’s Strategic plan;consideration of the results of prior internal audit work and other assurance reports;consideration of the Public Sector Internal Audit Standards; andthe wider context of the NHS sector in which the Trust operates.

Basis of our audit planAs noted above the starting point for our risk assessment, and for the development of the Internal Audit plan,was to understand the corporate objectives and risks of the Trust, and to map these against auditable units.

For auditable units which are not reviewed every year, the appropriate proportion of units are included in theplan each year (i.e.: the majority of all auditable units are covered every two years, and low risk auditable unitsare covered every three years). Details of the correlation between the audit requirement rating and thefrequency of audit work are available in section 3 below.

It is important to note that our audit plan only routinely covers those auditable units which are considered to bewithin the scope of our annual assurance programme, deemed ‘Value Protection’ in the Audit Universe. Otherareas identified as ‘Value Enhancement’ in the Audit Universe may be subject to review based on assessed riskor priority, but are not routinely assured within the plan.

Basis of our annual internal audit conclusionInternal audit will be performed in accordance with the Public Sector Internal Audit Standards. The PublicSector Internal Audit Standards are not designed or intended to conform to the International Standards onAssurance Engagements issued by the International Auditing and Assurance Standards Board. As aconsequence our work was not designed to comply with the International Standards on AssuranceEngagements. Our work was designed to comply with the Public Sector Internal Audit Standards which must befollowed for the NHS.

1. Introduction and approach


Our annual internal audit opinion will be based on and limited to the internal audits we have completed overthe year and the control objectives agreed for each individual internal audit. The agreed control objectives willbe reported within our final individual internal audit reports.

Other considerationsWe believe that the Trust and the Audit Committee would benefit from developing an Assurance Map. Anassurance map provides an overview of the key risks/ functions within an organisation and an oversight of theassurances roles, responsibilities and outcomes categorised by the three lines of defence. The 1st line of defenceincludes the policies, procedures and control design; the 2nd line being the government and managementassurance and the 3rd line being independent assurance e.g. internal audit and regulators.

At Appendix 2 we have included the key performance indicators we will use to monitor and measure ourperformance throughout the year for your consideration and approval.

Next stepsThe Audit Committee and the management are invited to consider and comment on the indicative auditprogramme and to comment on:

Whether there are additional areas which warrant inclusion within the programme;Consider and agree the key performance indicators; andThe prioritisation of areas for review.

We will revisit the plan throughout the year to ensure that it continues to meet your key risks and priorities.


2. Audit UniverseAudit universeThe diagram below represents the high level auditable units within the audit universe of the Trust. These unitsform the basis of the internal audit plan.

Bolton NHS FT

Strategy andGovernance

Governance

Riskmanagement

Compliance withstandards

Communications

Strategy &Improvement

HR

IT

Divisons

Elective

Adult Acute

Family care

Finance andprocurement

Financialmanagement

Businesssupport

Procurement

Operations

OperationsDivisons

Estates andfacilities

Location and keyrelationships

Monitor

CQC

Local CCGs /Trusts


Risk assessment resultsOur recommended planning approach involves scheduling the frequency of an audit based on our riskassessment of the inherent risk and the control environment. For year one we have flexed the standardapproach and primarily based on our risk assessment based upon ‘work to date’ set out in Section 1. Next yearwe will refine our approach to take account of our assessment of the control environment and the outcome ofthe assurance mapping exercise. The resources for the delivery of the internal audit plan are determined bymanagement and Audit Committee taking into account the risk appetite of the Trust.

Based on the results of our risk assessment we have determined the frequency with which an audit of that unitis required, this is set out below.

Key to audit requirement ratingsColour Code Frequency Description

Annual Review of processing/monitoring control designand operating effectiveness

Every two years Review of processing/monitoring control designand operating effectiveness

Every three years Review of processing/monitoring control designand operating effectiveness

No further work N/A

- Exceptional/One-off pieces of work

Ref Auditable Unit AuditRating

Frequency Comments

A Governance, regulation andcompliance

A1 Assurance Framework and Riskmanagement

Annual We are required to perform work in thisarea to inform our annual opinion andyour annual governance statement.

A2 Quality Governance Annual To review the Trust arrangements forQuality governance, including clinicalaudit , the Trusts response to Francisand Keogh and any specific point fromthe work undertaken by Deloittes

A3 Monitor action plans One off - year one To provide assurance on the actionstaken by the Trust to implement therecommendations made in the variousreports in response to Monitorrequirements.

3. Risk assessment



Frequency Comments

A4 Compliance with standards andregulatory returns

Annual Each year we will review the Trust’sarrangement for ensure complianceagainst regulatory requirements (such asCQC and Monitors RAF on a rotationalbasis)

A5 Governance / Committeeeffectiveness

Every two years Review of committee effectiveness on arational basis. In additional to this wewill provide ongoing support and adviceto the audit committee

B Financial systems and controls

B1 Key Financial systems and controlsPayroll & expensesCreditor and paymentGeneral ledgerIncome and debtorsCash and bank

Annual We are required to perform work in thisarea to inform our annual conclusion,and to support the external auditors.Review of key financial controlsintroducing computer auditingtechniques and or continuousmonitoring basis.

B2 Financial management andreporting

Annual Including financial management andreport at divisional level.

B3 Budgetary control Every two years A review of the processes in place forfinancial planning, budget setting andforecasting.

B4 Finance transformation Every two years We will review the outcome s from therecent finance function review andintroduce a programme of work tosupport to the required improvementsidentified and assurance onimplementation of recommendations.

B5 Capital asset/ accounting Every three years Undertaken based on the frequency inrelation to the key financial systems.

B6 Charitable funds Every three years Undertaken based on the frequency inrelation to the key financial systems.

C Information Technology

C1 IT general controls Every two years It is a requirement within the publicsector internal audit standards forinternal audit to assess whether the ITgovernance of the organization supportstheir strategies and objectives.

C2 Information governance Every two years Review of records management forcompliance with DPA. Sample testing ofIGT requirements self-assessmentprocesses and underlying evidence base

C3 IT service resilience and disasterrecovery

Every two years Review of Trust wide business continuityarrangements including the underlying



Frequency Comments

business impact assessment and extentto which testing has been undertaken toprovide reassurance of ability tocontinue / restore operations in theevent of an interruption event. Year onewill have a particular focus on ITresilience in the Community.

C4 IT projects (project / programmeassurance)

Every two years Timing of work to support EDMS andEPR project. We will undertake a seriesof reviews to assess the readiness,governance and management of majorprojects.

C5 Data governance /migration/assurance

Every two years Identified within the IT risk registerproject in place to prepare PbR billingand CDS data from 1-Apr-14.Also consider accuracy, completenessand validity of community services datadue to use of various systems that arenot integrated.

C6 Clinical coding Every two years The accuracy and completeness ofclinical coding is key to determining thecorrect levels of income and clinicalperformance of the Trust.

D Clinical Divisions / Operational areas

D1 Divisions - Acute, Family andElective / ward visits

Annual Across each Division: Adult Acute,Family Care & Elective Care we willintroduce a structured programme ofvisits to department and wards to testthe level of compliance with keyoperational, clinical and financialcontrols across the Trust’s controlenvironment.

D2 Cost improvement plans Annual Review key areas and/or projectsrelating to the Trust deliverabilityagainst its CIPs.

D3 Workforce and OrganisationalDevelopment

Every two years On a rotational basis look at the keysystems in relation to HR such asrecruitment, performance management,MAST, workforce planning ,sicknessabsence and staff communication &engagement.

D4 Estates Every two years On a rotational basis review keyssystems such as the estates strategy,repair & maintenance, disposals, majorprojects and health & safety.

D5 Non financial performancereporting / data quality

Annual Good quality data is vital in making keydecisions at both an operational



Frequency Comments

(including patient care decisions) and ata strategic level within the Trust. Weaim to assess the robustness andreliability of information provided to theBoard on non financial and clinicalperformance, assessing this against bestpractice and how the Trust use thisinformation.

D6 Serious Incidents/ complaints andclaims

Every two years How the Trust responds to and dealswith SI’s and complaints has asignificant impact on patient safety, thequality of care and the patientexperience.

D7 Procurement and contractmanagement

Every two years Consider the Trust’s overallarrangements for procurement. We willalso review the framework underpinningthe management of contracts for supplyof services to the Trust, drilling downinto their application for a range ofcontracts in areas such as IT andmedical supplies.

D8 Service integration Annual A review of the Trust’s programmes andplans to improve service integrationbetween the Trust and Community andan assessment how and if benefits arerealised.

D9 Stakeholder engagement andrelationship management

Every three years The NHS reforms have changed thenational and local landscapes. Effectivestakeholder engagement andrelationships management will beimportant to the Trust future success..

D10 Discharging and outpatients Every two years A key function and major influence onthe patient experience.

E Other

E1 Follow-up Annual Undertake a comprehensive stock takeof all previous internal auditrecommendations and develop astructured programme of annual review.

E2 Assurance mapping One off - year one To assist the Trust in developing anAssurance map to provide oversight tothe Audit Committee where the Trustgets its assurances from.


2013/14 annual internal audit plan and indicative timeline

The following table sets out the internal audit work planned for 2013/14 and identifies the type of review whichare categorised as:

Value protection (VP) – provides assurance over your current governance, risk management and controlarrangements, which constitutes a traditional controls assurance methodology.

Value enhancement (VE) - is focused on assessing future risks, such as looking at your new projects /systems and improving your performance, by, for example, identifying opportunities for efficiency gains, savingmoney and improving quality.

Ref Auditable Unit Type Noofauditdays

2013/14 2014/15

2015/16

Comments onplanned scope for2013/4Q

1Q2

Q3 Q4

A Governance, regulationand compliance

A1 Assurance Framework andrisk management

VP 10 - - - 10 10 10 A review of the riskmanagementarrangements and BAFfollowing improvementrecommendationsidentified as part of theGood Governance review.

A2 Quality governance VP 8 - - - 8 10 10 Pick up onrecommendations fromDeloittes report, withannual reviews thereafter

A3 Compliance with standardsand regulatory requirements

VP - - - - - 10 -

A4 Governance / Committeeeffectiveness

VE - - - * * 10 - * We will provide ad-hocadvice to the auditcommittee as appropriatethroughout the year

B Financial systems &controls

B1 Key Financial controls VP/VE 20 - - 10 10 20 20 We will develop ofprogramme of reviewingthe key financial controls

4. Indicative Audit Plan andTimings



2013/14 2014/15

2015/16


1Q2

Q3 Q4

through the use of dataanalytics and continuousmonitoring.

B2 Financial management andreporting

VP 10 - - 10 - 10 10 We will review financialmanagement andreporting arrangementacross the Trust includingClinical Divisions.

B3 Budgetary controls VP 8 - - - 8 - - A review of the Trustfinancial planning andbudgeting processes forFY14/15

B4 Finance transformation VE - - - - - 10 -

B5 Capital assets/ accounting VP - - - - - - 8

B6 Charitable funds VP - - - - - - 8

C Information technology

C1 IT general controls VP/VE 10 - - 10 - - 10 We will perform an ITrisk diagnosticassessment which willtest the robustness of thecontrol environment.

C2 Information governance VP - - - - - 10 -

C3 IT service resilience & disasterrecovery

VE 10 - - - 10 10

C4 IT projects (project/programme assurance)

VE - - - 10 - 10 - A review of the Trustsproject assurancearrangements over keyprogrammes and projects

C5 Data governance/ migration/assurance

VE - - - - - 15 -

C6 Clinical coding VE - - - - - 10 -

D Clinical Divisions andOperational areas

D1 Division / ward visits VP 20 - - 10 10 20 20 We will undertake aprogramme of work to



2013/14 2014/15

2015/16


1Q2

Q3 Q4

test the robustness of thecontrol environmentcompliment the 'ward at aglance’ performancedashboard.

D2 Cost improvement plans VE 15 - - 15 - 15 15 An annual review ofimplementation anddelivery of the Trust’sCIPs.

D3 Workforce and OD VP/VE - - - - - 10 -

D4 Estates VP/VE 8 - - 8 - - 10 Focus on the repairs andmaintenance programmein year 1.

D5 Non financial performancereporting / data quality

VE 20 - - 10 10 15 10 Over the 3 yearsprogramme of work wewill take a holisticapproach to look at hownon financial date iscaptured and reported tothe Board and how theinformation is used toinform the decisionmaking processes.

D6 Serious Incidents/ complaintsand claims

VE - - - - 10 0 Included within f/u inyear1 and a more detailedreview of the Trust’sarrangements forresponding to andhandling SI’s andcomplaints andimplementing lessonslearnt in Y2

D7 Procurement and contractmanagement

VP/VE - - - - - 10 -

D8 Service integration VE 10 - - 10 - 10 10 A review of the Trust’sservice integration plansand providing assuranceon its implementation.

D9 Stakeholder engagement andrelationship management

VE - - - - - 10 -

D10 Discharging and outpatients VE - - - - - 10

E Other

Follow-up VP 10 - - 5 5 5 5 Focus on following uphigh riskrecommendations



2013/14 2014/15

2015/16


1Q2

Q3 Q4

identified, in particularmedicine management,clinical waste, anddischarge planning.

Assurance mapping 10 - - 10 - - - Specialist piece of work.

Monitor Action plans 10 - - 10 - - - Additional to the IA Plan.We will review the actionsundertaken by the Trustto implement therecommendation relevantto Monitors actions plans.

Planning, management andattendance at auditcommittees

- 20 - 5 10 5 20 20

Contingency - 5 - - - 5 - 10

Yr 1quartertotals

204 0 5 118 81 225 209

ANNUAL GRAND TOTAL 204 218 206


Name Title

David Wakefield Chairman

Mark Harrison Vice Chairman

Carol Davies Chair of Audit Committee

Allan Duckworth Chair of Finance Committee

Simon Worthington Director of Finance

Jon Scott Chief Operating Officer

Trish Armstrong-Child Director of Nursing

Jackie Bene Medical Director

Andrea Bennett Deputy Director of Finance

Phil Bailey Head of Management Accountants

Catherine Hulme Head of Financial Services

Shelia Robertson Interim Associate Director of Operations, Family Care Division

Rae Wheatcroft Associate Director of Operations, Elective Care Division

Ranjani Beveridge Associate Director of Operations, Acute Adult Care

Joe Heaney General Manager ,Acute Adult Care

Esther Steel Associate Director of Corporate Governance and PublicEngagement/Trust Secretary

Rachel Dunscombe Chief Information Officer

Stephen Tyldsley Head of Estates - Associate Director of Operations, Estates & Facilities

Nicky Ingham Head of Human Resource - Director of Workforce & OrganisationalDevelopment

Collette Ryan Local Counter Fraud Specialist

Appendix1:List of Interviewees


Key performance indicatorsTo ensure your internal audit service is accountable to the Audit Committee and management, we haveproposed the following key performance indicators. We are happy to discuss any further KPI’s that the Trustwant to use to monitor the performance of our service with the Audit Committee.

KPI Target

Contract activity

Audit coverage v audit plan – % complete 100%

Actual cost compared with Budget Meet agreed budget

Planning

Presentation and agreement of the annual internalaudit plan

To be presented at the April /May Audit Committeemeeting.

Reporting

Issue of Draft Reports Within 10 working days of closure of fieldwork

Issue of Final Reports Within 5 working days of receiving managementresponses

Issue of internal audit progress reports Internal audit progress report to be issued to eachAudit Committee meeting

Issue of Internal Audit annual report To be presented at the May Committee meeting

Follow ups

Timeliness of follow ups on recommendations made Recommendations to be followed up within one yearof the report being agreed and finalised

Relationships

Overall client satisfaction score 8 out of 10

Appendix 2: Key performanceindicators

In the event that, pursuant to athe Freedom of Information Actsubordinate legislation made thecontained in this terms of referinformation. The Trust agrees tosuch disclosure and to apply afollowing consultation with PwC,PwC has included or may subsdisclosed.This document has been prePricewaterhouseCoopers LLP dor reliance on this document bycontract for the matter toPricewaterhouseCoopers LLP at© 2013 PricewaterhouseCooPricewaterhouseCoopers LLP (aPricewaterhouseCoopers Interna

request which the Bolton NHS Foundation Trust (“thet 2000 (as the same may be amended or re-enacteereunder (collectively, the “Legislation”), it is requiredrence, it will notify PwC promptly and consult with Po pay due regard to any representations which PwC many relevant exemptions which may exist under the

the Trust discloses any such information, it shall ensusequently wish to include in the information is repro

epared for the intended recipients only. To theoes not accept or assume any liability, responsibility o

y anyone, other than (i) the intended recipient to the ewhich this document relates (if any), or (ii)

t its sole discretion in writing in advance.opers LLP. All rights reserved. In this doca limited liability partnership in the United Kingdom),ational Limited, each member firm of which is a separa

e Trust”) has received underd from time to time) or any

d to disclose any informationPwC prior to disclosing suchmay make in connection with

Act to such information. If,ure that any disclaimer whichoduced in full in any copies

extent permitted by law,or duty of care for any use ofextent agreed in the relevant

as expressly agreed by

cument, "PwC" refers to, which is a member firm of

ate legal entity.

ned S ve Income o 2

t t R inc 160.7 164.3 161.2 158.0 156.8 155.6

inc 92.1 92.8 91.6 90.4 89.3 88.1me -4.3 -2.3 -2.3 -2.3 -2.3 -2.3

l In 26.0 25.7 25.3 25.0 24.7 24.4 i

y -197.6 -188.7 -180.7 -173.9 -170.9 -168.3-76.6 -76.6 -76.0 -76.3 -76.1 -75.7

Risk 1.0 -3.2 -4.1 -4.1 -4.1 -4.1-5.2 -6.1 -7.1 -7.4 -7.4 -7.4

C / Inter -3.9 -4.3 -4.8 -4.8 -4.8 -4.8 E e

%

me / st Ime / st I ts %

ty of S R

2 State nt o F Po n /14 to 2

£ £ £ £ £ £ ts, N t

0.4 0.4 0.4 0.4 0.4 0.4 t 121.3 132.7 145.7 148.3 148.7 149.1

r Rec 1.1 1.1 1.1 1.1 1.1 1.1t r Bad &

(0.1) (0.1) (0.1) (0.1) (0.1) (0.1)ts, N t,

ts, C t 1.3 1.3 1.3 1.3 1.3 1.3

3.6 3.6 3.6 3.6 3.6 3.6 0.5 0.5 0.5 0.5 0.5 0.5r Rec 2.5 2.5 2.5 2.5 2.5 2.5

t t r b & (0.6) (0.6) (0.6) (0.6) (0.6) (0.6)

2.7 2.7 2.7 2.7 2.7 2.7 1.3 1.3 1.3 1.3 1.3 1.3

th Go t 0.3 1.0 1.6 3.0 3.6 4.5ts, C t,

s, Cur t t (1.4) (2.8) (4.4) (4.8) (4.9) (4.9)

(0.2) (0.2) (0.2) (0.2) (0.2) (0.2)t x (3.8) (3.8) (3.8) (3.8) (3.8) (3.8)

(8.2) (8.7) (8.7) (8.7) (8.7) (8.7)r Pa (4.7) (4.7) (4.7) (4.7) (4.7) (4.7)

(0.4) (0.4) (0.4) (0.4) (0.4) (0.4) (1.2) (1.2) (1.2) (1.2) (1.2) (1.2) (1.3) (1.3) (1.3) (1.3) (1.3) (1.3)

(0.4) (0.4) (0.4) (0.4) (0.4) (0.4) 0.0 0.0 0.0 0.0 0.0 0.0

t t (0.3) (0.3) (0.3) (0.3) (0.3) (0.3)

s, Cur t,

T NT TS (

s, N t

(18.5) (27.1) (36.0) (35.0) (30.8) (26.6) (0.3) (0.3) (0.3) (0.3) (0.3) (0.3)

s, N t,

TS E

s E 102.0 102.0 102.0 102.0 102.0 102.0

(37.4) (35.8) (32.7) (28.1) (23.0) (17.5) 29.0 29.0 29.0 29.0 29.0 29.0

TY,

3 State nt o C h 2 to

£ £ £ £ £ 6.1 7.1 7.4 7.4 7.4

3.7 4.2 4.2 4.2 4.2r i m

0.6 0.6 0.6 0.6 0.6 s in op g su , T

g Cash s bef e move ts g c

g c 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 r re 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 tax pa 0.0 0.0 0.0 0.0 0.0 0.5 0.0 0.0 0.0 0.0 r C 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 r F 0.0 0.0 0.0 0.0 0.0 g c , T

Net m g act

Net m g act t & -17.5 -21.9 -10.9 -7.8 -7.8 t 0.0 1.8 0.9 0.0 0.0

0.0 0.0 0.0 0.0 0.0

Net m g act s, Total

Net e f

Net m g act 0.0 0.0 0.0 0.0 0.0

-3.7 -4.2 -4.2 -4.2 -4.2t -0.6 -0.6 -0.6 -0.6 -0.6

11.4 14.8 3.5 0.4 0.4t -1.4 -4.3 -4.1 -4.5 -4.6

Net m g act s, Total

Net

g c

g c

4 f 14 19

2014/15 2015/16 2016/17 2017/18 2018/19Liquidity Ratio £m £m £m £m £mCash 1.0 1.6 3.0 3.6 4.5Debtors 4.1 4.1 4.1 4.1 4.1Accrued income 2.7 2.7 2.7 2.7 2.7Impairment of receivables (0.6) (0.6) (0.6) (0.6) (0.6)Other debtors 2.5 2.5 2.5 2.5 2.5Prepayments 1.3 1.3 1.3 1.3 1.3PDC ReceivableTrade creditors (8.7) (8.7) (8.7) (8.7) (8.7)Other creditors (4.7) (4.7) (4.7) (4.7) (4.7)Provisions (0.2) (0.2) (0.2) (0.2) (0.2)Tax (3.8) (3.8) (3.8) (3.8) (3.8)Capital Payables (0.4) (0.4) (0.4) (0.4) (0.4)Accruals (1.2) (1.2) (1.2) (1.2) (1.2)Payments on Account (1.3) (1.3) (1.3) (1.3) (1.3)Finance Leases < 1 year (0.4) (0.4) (0.4) (0.4) (0.4)PDC Dividend 0.0 0.0 0.0 0.0 0.0Interest Payable (0.3) (0.3) (0.3) (0.3) (0.3)Loans (2.8) (4.4) (4.8) (4.9) (4.9)Working Capital per plan @31/03/13 (12.8) (13.8) (12.8) (12.3) (11.4)Additional loan repayments due within 1 yearCash movement (cumulative)Working capital adjustmentWorking Capital (12.8) (13.8) (12.8) (12.3) (11.4)

Total expenses 278.9 272.7 266.5 263.3 260.2 Depreciation 6.1 7.1 7.4 7.4 7.4 Depreciation - ITDepreciation - EstatesOperating expenses 272.8 265.6 259.1 255.9 252.8 No. of days 360 360 360 360 360 Rating 4 3 2 1Liquidity raio (in days) 16.89- 18.70- 17.78- 17.30- 16.23- Proposed liquidity ratio (days) 0 -7 -14 <-14

Liquidity rating 1 1 1 1 1

Capital Servicing CapacitySurplus / (Deficit) - per forecast 1.6 3.1 4.6 5.1 5.5Surplus adjustmentRevisedSurplus / (Deficit) 1.6 3.1 5 5 5

Opening financing:Taxpayers equity 93.6 95.2 98 103 108 Leases 0.4 0.4 0 0 0 Borrowing 19.9 29.9 40 40 36

113.9 125.5 139 143 144

Closing FinancingTaxpayers equity 95.2 98.3 102.9 108.0 113.5 Leases 0.4 0.4 0.4 0.4 0.4 Borrowing 29.9 40.4 39.8 35.7 31.5

125.5 139 143 144 145 Rating 4 3 2 1Proposed capital servicing ratio 2.5 1.75 1.25 <1.25

Capital Servicing Capacity 0.0134 0.0234 0.0326 0.0355 0.0380

Capital Servicing Capacity Rating 2 3 4 4 4

Overall Rating 2 2 3 3 3

2014/15 2015/16 2016/17 2017/18 2018/191 1 1 1 12 3 4 4 42 2 3 3 3

FORECAST

Summary Rating (loans)Liquidity ratingCapital Servicing Capacity RatingOverall Rating

5 f 14 19

2014/15 2015/16 2016/17 2017/18 2018/19Liquidity Ratio £m £m £m £m £mCash 1.0 3.0 7.4 11.4 15.8Debtors 4.1 4.1 4.1 4.1 4.1Accrued income 2.7 2.7 2.7 2.7 2.7Impairment of receivables (0.6) (0.6) (0.6) (0.6) (0.6)Other debtors 2.5 2.5 2.5 2.5 2.5Prepayments 1.3 1.3 1.3 1.3 1.3PDC ReceivableTrade creditors (8.7) (8.7) (8.7) (8.7) (8.7)Other creditors (4.7) (4.7) (4.7) (4.7) (4.7)Provisions (0.2) (0.2) (0.2) (0.2) (0.2)Tax (3.8) (3.8) (3.8) (3.8) (3.8)Capital Payables (0.4) (0.4) (0.4) (0.4) (0.4)Accruals (1.2) (1.2) (1.2) (1.2) (1.2)Payments on Account (1.3) (1.3) (1.3) (1.3) (1.3)Finance Leases < 1 year (0.4) (0.4) (0.4) (0.4) (0.4)PDC Dividend 0.0 0.0 0.0 0.0 0.0Interest Payable (0.3) (0.3) (0.3) (0.3) (0.3)Loans (1.4) (1.4) (1.4) (1.4) (1.4)Working Capital per plan @31/03/13 (11.4) (9.4) (5.0) (1.0) 3.4Additional loan repayments due within 1 yearCash movement (cumulative)Working capital adjustmentWorking Capital (11.4) (9.4) (5.0) (1.0) 3.4

Total expenses 278.9 272.7 266.5 263.3 260.2 Depreciation 6.1 7.1 7.4 7.4 7.4 Depreciation - ITDepreciation - EstatesOperating expenses 272.8 265.6 259.1 255.9 252.8 No. of days 360 360 360 360 360 Rating 4 3 2 1Liquidity raio (in days) 15.04- 12.74- 6.95- 1.41- 4.84 Proposed liquidity ratio (days) 0 -7 -14 <-14

Liquidity rating 1 2 3 3 4

Capital Servicing CapacitySurplus / (Deficit) - per forecast 1.6 3.1 4.6 5.1 5.5Surplus adjustmentRevisedSurplus / (Deficit) 1.6 3.1 5 5 5

Opening financing:Taxpayers equity 93.6 106.6 125 133 138 Leases 0.4 0.4 0 0 0 Borrowing 19.9 18.5 16 15 13

113.9 125.5 141 148 152

Closing FinancingTaxpayers equity 106.6 124.5 132.6 138.1 144.0 Leases 0.4 0.4 0.4 0.4 0.4 Borrowing 18.5 15.6 14.5 13.4 12.3

125.5 141 148 152 157 Rating 4 3 2 1Proposed capital servicing ratio 2.5 1.75 1.25 <1.25

Capital Servicing Capacity 0.0134 0.0233 0.0319 0.0341 0.0356

Capital Servicing Capacity Rating 2 3 4 4 4

Overall Rating 2 3 4 4 4

2014/15 2015/16 2016/17 2017/18 2018/191 2 3 3 42 3 4 4 42 3 4 4 4

FORECAST

Summary Ratings (PDC)Liquidity ratingCapital Servicing Capacity RatingOverall Rating

ve

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bR

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0.8

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-0.3

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-1.8

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10.5

1.9

-0.7

-1.7

-3.0

8.1

0.3

-0.7

-1.7

-2.9

7.6

0.2

-0.6

-0.2

-2.5

2.7

-1.0

0.3

-2.5

2.5

-0.1

0.4

-2.5

2.9

0.0

0.0

-0.3

-0.2

-0.1

0.0

0.0

0.0

0.0

-0.3

0.0

0.0

0.0

0.0

0.0

0.0

.7 Income - D ailed Bridge An 20 /15 to 2

t P Tariff changes -3.6 -3.7 -3.6 -3.6 -3.5Activity impact 2.0 -1.4 -1.4 0.5 0.5Income improvements 7.7 0.4 0.4 0.4 0.4

n

H I 1) Generic Tariff deflation @ 1.3% -3.3 -3.3 -3.3 -3.2 -3.22) Generic Income deflation - divisional income -0.3 -0.3 -0.3 -0.3 -0.33) Activity Activty growth - Demographic - Acute 2.0 1.8 1.8 1.8 1.94) Activity Activty growth - Demographic - Community 1.0 0.8 0.9 0.8 0.85) Activity Activty growth - Residual - Acute 2.5 2.6 2.6 2.6 2.66) Activity Integration - savings - Acute -1.9 -3.8 -1.9 0.0 0.07) Activity Integration - investment - Community 2.0 2.0 0.0 0.0 0.08) Activity Stroke reconfiguartion -1.0 0.0 0.0 0.0 0.09) Activity QIPP - additional to integration -4.7 -4.7 -4.7 -4.7 -4.810) Activity Non Eelctive - Marginal Rate 1.4 0.0 0.0 0.0 0.011) Improve PBR Data quality 0.8 0.0 0.0 0.0 0.012) Improve Contractual performance 2.0 0.0 0.0 0.0 0.013) Improve Community - Activity catch up 1.9 0.0 0.0 0.0 0.014) Improve Community - Staffing ratio catch up 1.1 0.0 0.0 0.0 0.015) Improve CQUINs to 100% 1.5 0.0 0.0 0.0 0.016) Activity Community - IT Infrastructure transfer 0.5 0.0 0.0 0.0 0.017) Activity Community - Impact of £1.9m IT invest 0.4 0.0 0.0 0.0 0.018) Improve Community - fixed staffing ratios 0.4 0.4 0.4 0.4 0.4

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7.7

7.7

7.7

7.7

7.7

7.7

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7.7

7.6

7.6

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5.7

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-6.5

-6.5

-6.5

-6.4

-6.4

-6.4

-6.3

-6.3

-6.3

-6.2

-6.2

-6.2

-6.5

-6.5

-6.5

-6.4

-6.4

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SIncome 7,303 367 367 367 367 8,771Cost - Pay 10,797 11,045 10,502 8,083 7,615 48,042Cost - Non Pay 4,100 4,088 2,731 2,450 2,918 16,287

inc and im % im %

im %

1) Income PBR Data quality 800 0 0 0 0 8002) Income Contractual performance 2,000 0 0 0 0 2,0003) Income Community - Activity catch up 1,900 0 0 0 0 1,9004) Income Community - Staffing ratio catch up 1,103 367 367 367 367 2,5715) Income CQUINs to 100% 1,500 0 0 0 0 1,5006) Cost - Pay Grade Mix 1,300 1,300 6,500 0 0 9,1007) Cost - Pay Bed Reductions 2,612 3,040 1,300 1,085 0 8,0378) Cost - Pay 30 Day Readmission - to upper quartile 476 200 0 0 0 6769) Cost - Pay Day case rates - to upper quartile 73 0 0 0 0 7310) Cost - Pay Outpatient procedures - to upper quartile 420 200 0 0 0 62011) Cost - Pay Outpatient DNA Rates 410 300 0 0 0 71012) Cost - Pay Other acute staff - productivity 2,200 2,200 1,100 1,045 993 7,53813) Cost - Pay Community - Management costs 575 0 0 0 0 57514) Cost - Pay Community - IT - Travel scheduling 144 754 300 0 0 1,19715) Cost - Pay Community - IT - Record keeping 113 721 300 0 0 1,13416) Cost - Pay Community - Indirect costs @ 2% 195 205 430 215 215 1,26017) Cost - Pay Community - Priority based review 400 0 0 0 0 40018) Cost - Pay Corporate - Priority review 750 0 0 0 0 75019) Cost - Pay Corporate - Staff Efficiency 1,000 769 731 694 660 3,85420) Cost - Pay Sickness rate reductions 300 300 300 300 300 1,50021) Cost - Pay Pay reform - increments 500 0 0 0 0 50022) Cost - Pay Fixed Staffing Ratios 1,629 544 544 544 544 3,80523) Cost - Non Pay Corporate - Consultancy 1,200 0 0 0 0 1,20024) Cost - Non Pay Non Pay - Clinical 0 1,150 1,000 1,000 1,000 4,15025) Cost - Non Pay Non Pay - Non Clinical 2,900 2,600 750 700 700 7,65026) Cost - Pay Provider efficiency assumption - Pay 900 5,413 3,097 8,300 9,003 26,71327) Cost - Non Pay Provider efficiency assumption - Non Pay 0 338 981 750 1,218 3,28728) Cost - Pay Risk Reserve -3,200 -4,900 -4,100 -4,100 -4,100 -20,400

0 ned Cap pend 2 5 o 2

Buildings - ongoing 3,992 4,992 5,292 5,292 5,292Plant & equipment 1,396 1,396 1,396 1,396 1,396Furniture 39 39 39 39 39Office & IT Equip. 265 265 265 265 265Software licenses 142 142 142 142 142Leased asset 266 266 266 266 266Estates Strategy 5,636 9,009 2,030 0 0IT Strategy 5,800 5,796 1,465 357 357

H.11 E s S y - Fore st & Ca l 2 t 2

Impact Capital Costs 5,636 9,009 2,030 0 0 16,675Capital Receipts 0 -1,833 -917 0 0 -2,750Mortage / Loan Repayment 0 1,500 0 0 0 1,500

et

e t Revenue Costs of Demolition 518 686 358 0 0 1,563New Depreciation Charge 207 523 596 596 596 2,517Capital Charges 199 496 548 527 506 2,276Savings -43 -1,112 -1,681 -1,859 -1,859 -6,554

IT Strategy - F t Revenue & Capital Spend 201 to 2

l Full EPR implementation charges 0 2,500 500 0 0 3,000Hardware/infrastructure costs 0 0 200 200 200 600Hardware/infrastructure costs + refresh 0 1,000 0 0 0 1,000iPM merge 80 0 0 0 0 80Supplier Hardware 156 0 0 0 0 156Supplier Software 550 0 0 0 0 550Supplier Implementation 180 0 0 0 0 180Supplier Records Scanning 1,933 967 0 0 0 2,900Data lines 152 0 0 0 0 152Enviroment/Building work 369 82 82 82 82 696Network equipment 95 0 0 0 0 95VDI terminal 421 0 0 0 0 421Licence costs 541 0 0 0 0 541Storage costs 72 12 12 12 12 120Consultancy Implementation costs 651 1,161 608 0 0 2,420Trust Support (External Co buy in) 31 63 63 63 63 283Trust Implementation (External Co buy in) 568 12 0 0 0 580

e CSC iPM PAS extension 0 0 213 425 425 1,063Extramed 202 130 99 0 0 431Licence charge for full EPR 0 700 1,400 1,400 1,400 4,900Ongoing system administration (Salford) 0 125 250 250 250 875Supplier Maintenance & Support 63 127 127 127 127 571Supplier Records Destruction 48 25 1 1 0 75Supplier Records Transport 57 29 1 1 1 89Data lines 232 143 143 143 143 804Network equipment 19 19 19 19 19 95Licence costs 108 108 108 108 108 541SLA Costs 240 0 0 0 0 240Hardware Support 19 19 19 19 19 94Depreciation 725 1,450 1,633 1,677 1,722 7,206Loan interest at 3.5% 235 348 346 300 253 1,482

3a sh Flow n - IT d Es s d by

'm 'm 'm 'm 'm C

I&E Surplus 1.6 3.1 4.6 5.1 5.5Depreciation 6.1 7.1 7.4 7.4 7.4Working Capital Improvement 0.5 0.0 0.0 0.0 0.0Capital Spend (17.5) (21.9) (10.9) (7.8) (7.8)Capital Receipt 0.0 1.8 0.9 0.0 0.0Repayment of loan re land(due to sale) 0.0 (1.5) 0.0 0.0 0.0Existing Loan Payment (1.4) (1.4) (1.1) (1.1) (1.1)New Loans 11.4 14.8 3.5 0.4 0.4New Loan repayment 0.0 (1.4) (3.0) (3.4) (3.5)

C sh

3b sh Flow n - IT d Es s d by

'm 'm 'm 'm 'm C

I&E Surplus 1.6 3.1 4.6 5.1 5.5Depreciation 6.1 7.1 7.4 7.4 7.4Working Capital Improvement 0.5 0.0 0.0 0.0 0.0Capital Spend (17.5) (21.9) (10.9) (7.8) (7.8)Capital Receipt 0.0 1.8 0.9 0.0 0.0Repayment of loan re land(due to sale) 0.0 (1.5) 0.0 0.0 0.0Existing Loan Payment (1.4) (1.4) (1.1) (1.1) (1.1)New PDC 11.4 14.8 3.5 0.4 0.4New Loan repayment 0.0 0.0 0.0 0.0 0.0

C sh

H.14 oan Re n - 4/15 to 201

'm 'm 'm 'm 'mg Mi L

New loan drawdownRepayment 1.1 1.1 1.1 1.1 1.1

g Mi L

g Car LNew loan drawdownRepayment 0.3 1.8 0.0 0.0 0.0 include £ final paym o loan

g Car L

g Est s LNew loan drawdown -5.6 -9.0 -2.0Repayment 0.3 0.7 0.8 0.8

g Est s L

g I St LNew loan drawdown -5.8 -5.8 -1.5 -0.4 -0.4Repayment 1.1 2.3 2.6 2.7

g Est s L

g T LNew loan drawdown -11.4 -14.8 -3.5 -0.4 -0.4Repayment 1.4 4.3 4.1 4.5 4.6

g T L

DC FI

g CaI&E Surplus 1,640.7 3,105.4 4,557.9 5,083.1 5,486.4Depreciation 6,114.3 7,142.0 7,446.3 7,424.6 7,401.4Working Capital Improvement 500.0 0.0 0.0 0.0 0.0Capital Spend -16,396.0 -19,931.0 -8,596.0 -8,557.0 -8,557.0Capital Receipt 0.0 1,833.0 917.0 0.0 0.0Repayment of loan re land(due to s 0.0 -416.0 -208.0 0.0 0.0Existing Loan Payment -1,400.0 -1,400.0 -1,400.0 -1,400.0 -1,400.0New PDC 11,400.0 14,800.0 3,500.0 300.0 300.0New Loan repayment 0.0 0.0 0.0 0.0 0.0

g Ca

s

5 y cast S ry o 2

y typeA&E 114,427 111,872 109,893 108,518 107,071Day Cases 25,011 24,753 24,484 24,202 23,907Elective IP 6,738 6,676 6,611 6,543 6,472Non Elective IP 35,384 32,678 31,103 30,728 30,362OP - First 88,180 87,261 86,303 85,301 84,248OP - FUPs 142,646 141,149 139,588 137,957 136,241OP - Proc First 13,925 13,777 13,622 13,461 13,292OP - Proc FUPs 29,973 29,672 29,357 29,028 28,681Delivery Episodes 5,756 5,684 5,610 5,533 5,453Antenatal Pathways 6,267 6,189 6,108 6,024 5,937Postnatal Pathways 5,041 4,979 4,914 4,846 4,776Excess Bed Days 16,038 15,899 15,754 15,600 15,438Other 100 103 105 107 110

A Forec De 2 to

1 Elective Care General Surgery Day Cases 3,664 3,615 3,563 3,509 3,4542 Elective Care General Surgery Elective IP 1,556 1,539 1,521 1,503 1,4833 Elective Care General Surgery Non Elective IP 5,038 4,642 4,401 4,323 4,2424 Elective Care General Surgery OP - First 4,070 4,017 3,962 3,904 3,8455 Elective Care General Surgery OP - FUPs 6,044 5,965 5,884 5,799 5,7106 Elective Care General Surgery OP - Proc First 348 344 339 334 3297 Elective Care General Surgery OP - Proc FUPs 254 251 247 244 2408 Elective Care General Surgery XBD 1,936 1,914 1,891 1,868 1,8439 Elective Care Urology Day Cases 2,370 2,348 2,325 2,301 2,27610 Elective Care Urology Elective IP 690 685 680 674 66911 Elective Care Urology Non Elective IP 69 64 61 60 5912 Elective Care Urology OP - First 2,354 2,330 2,306 2,281 2,25413 Elective Care Urology OP - FUPs 5,921 5,863 5,802 5,738 5,67014 Elective Care Urology OP - Proc First 252 249 247 244 24115 Elective Care Urology OP - Proc FUPs 2,081 2,061 2,039 2,017 1,99316 Elective Care Urology XBD 44 44 44 43 4317 Elective Care Breast Surgery Day Cases 186 183 181 178 17518 Elective Care Breast Surgery Elective IP 254 251 248 244 24119 Elective Care Breast Surgery Non Elective IP 3 3 3 2 220 Elective Care Breast Surgery OP - First 1,812 1,788 1,764 1,738 1,71221 Elective Care Breast Surgery OP - FUPs 3,258 3,216 3,172 3,126 3,07822 Elective Care Breast Surgery OP - Proc First 552 545 537 529 52123 Elective Care Breast Surgery OP - Proc FUPs 974 961 948 934 92024 Elective Care Colorectal Surgery Day Cases 21 20 20 20 1925 Elective Care Colorectal Surgery Elective IP 6 6 6 6 626 Elective Care Colorectal Surgery Non Elective IP 6 5 5 5 527 Elective Care Colorectal Surgery OP - First 2,240 2,211 2,180 2,149 2,11628 Elective Care Colorectal Surgery OP - FUPs 2,562 2,528 2,494 2,458 2,42029 Elective Care Colorectal Surgery OP - Proc First 865 853 842 830 81730 Elective Care Colorectal Surgery OP - Proc FUPs 162 160 158 156 15331 Elective Care Upper Gastrointestinal Surgery Elective IP 6 6 6 6 632 Elective Care Upper Gastrointestinal Surgery OP - First 186 184 181 178 17633 Elective Care Upper Gastrointestinal Surgery OP - FUPs 3 3 3 3 334 Elective Care Vascular Surgery Elective IP 3 3 3 3 335 Elective Care Vascular Surgery Non Elective IP 3 3 3 2 236 Elective Care Vascular Surgery OP - First 1,104 1,089 1,074 1,059 1,04337 Elective Care Vascular Surgery OP - FUPs 1,676 1,654 1,632 1,608 1,58438 Elective Care Vascular Surgery OP - Proc First 139 137 135 133 13139 Elective Care Vascular Surgery OP - Proc FUPs 251 248 244 241 23740 Elective Care Trauma & Orthopaedics Day Cases 2,063 2,033 2,002 1,970 1,93741 Elective Care Trauma & Orthopaedics Elective IP 1,494 1,477 1,459 1,440 1,42142 Elective Care Trauma & Orthopaedics Non Elective IP 1,731 1,602 1,527 1,507 1,48643 Elective Care Trauma & Orthopaedics OP - First 19,810 19,571 19,322 19,063 18,79244 Elective Care Trauma & Orthopaedics OP - FUPs 24,277 23,983 23,678 23,361 23,02845 Elective Care Trauma & Orthopaedics OP - Proc First 68 67 66 65 6446 Elective Care Trauma & Orthopaedics OP - Proc FUPs 56 55 55 54 5347 Elective Care Trauma & Orthopaedics XBD 1,374 1,365 1,354 1,343 1,33148 Elective Care ENT Day Cases 1,325 1,311 1,296 1,280 1,26449 Elective Care ENT Elective IP 863 854 844 834 82450 Elective Care ENT Non Elective IP 444 410 389 383 37651 Elective Care ENT OP - First 2,975 2,942 2,908 2,873 2,83552 Elective Care ENT OP - FUPs 6,917 6,841 6,762 6,679 6,59253 Elective Care ENT OP - Proc First 2,830 2,799 2,767 2,733 2,69754 Elective Care ENT OP - Proc FUPs 3,975 3,931 3,885 3,838 3,78855 Elective Care ENT XBD 115 114 113 112 11056 Elective Care Ophthalmology Day Cases 6,101 6,082 6,062 6,039 6,01457 Elective Care Ophthalmology Elective IP 45 45 45 44 4458 Elective Care Ophthalmology Non Elective IP 20 19 18 17 1759 Elective Care Ophthalmology OP - First 9,719 9,648 9,572 9,492 9,40660 Elective Care Ophthalmology OP - FUPs 25,054 24,869 24,674 24,467 24,24661 Elective Care Ophthalmology OP - Proc First 2,938 2,916 2,893 2,869 2,84362 Elective Care Ophthalmology OP - Proc FUPs 9,518 9,447 9,373 9,295 9,21163 Elective Care Ophthalmology XBD 42 41 41 40 4064 Elective Care Oral Surgery Day Cases 1,428 1,412 1,396 1,379 1,36065 Elective Care Oral Surgery Elective IP 74 73 72 71 7066 Elective Care Oral Surgery Non Elective IP 3 3 2 2 267 Elective Care Oral Surgery OP - First 2,265 2,235 2,203 2,170 2,13568 Elective Care Oral Surgery OP - FUPs 2,357 2,325 2,292 2,257 2,22169 Elective Care Oral Surgery OP - Proc First 38 38 37 37 3670 Elective Care Oral Surgery OP - Proc FUPs 1,071 1,056 1,041 1,025 1,009

71 Elective Care Orthodontics OP - First 74 73 72 71 7072 Elective Care Orthodontics OP - FUPs 765 757 747 738 72873 Elective Care Maxillo-Facial Surgery OP - First 714 705 695 685 67574 Elective Care Maxillo-Facial Surgery OP - FUPs 44 44 43 42 4275 Elective Care Maxillo-Facial Surgery OP - Proc First 3 3 3 3 376 Elective Care Maxillo-Facial Surgery OP - Proc FUPs 9 9 9 8 877 Elective Care Plastic Surgery Day Cases 561 557 552 548 54378 Elective Care Plastic Surgery Elective IP 18 18 18 18 1879 Elective Care Plastic Surgery OP - First 728 724 719 714 70880 Elective Care Plastic Surgery OP - FUPs 1,230 1,223 1,215 1,206 1,19781 Elective Care Plastic Surgery OP - Proc First 51 50 50 50 4982 Elective Care Plastic Surgery OP - Proc FUPs 481 478 475 472 46883 Elective Care Paediatric Surgery Day Cases 149 148 147 146 14684 Elective Care Paediatric Surgery Elective IP 6 6 6 6 685 Elective Care Paediatric Surgery Non Elective IP 9 8 8 8 786 Elective Care Paediatric Surgery OP - First 532 530 527 524 52087 Elective Care Paediatric Surgery OP - FUPs 443 441 438 436 43388 Elective Care Cardiac Surgery OP - First 91 90 89 88 8689 Elective Care Cardiac Surgery OP - FUPs 32 32 32 31 3190 Elective Care Thoracic Surgery OP - First 92 91 90 89 8891 Elective Care Thoracic Surgery OP - FUPs 83 82 81 80 7992 Elective Care Anaesthetics Non Elective IP 14 13 12 12 1293 Elective Care Anaesthetics OP - First 30 29 29 28 2894 Elective Care Anaesthetics OP - FUPs 726 716 706 696 68595 Elective Care Pain Management Day Cases 526 520 514 507 50096 Elective Care Pain Management Elective IP 8 8 8 8 897 Elective Care Pain Management OP - First 661 652 643 633 62498 Elective Care Pain Management OP - FUPs 3,452 3,406 3,358 3,309 3,25799 Elective Care Paediatric Gastrointestinal Surgery OP - First 3 3 3 3 3100 Elective Care Paediatric Gastrointestinal Surgery OP - FUPs 27 27 26 26 26101 Elective Care Paediatric Trauma And Orthopaedics OP - First 399 396 394 392 389102 Elective Care Paediatric Trauma And Orthopaedics OP - FUPs 654 651 647 643 639103 Elective Care Paediatric Ear Nose And Throat OP - First 604 601 597 594 590104 Elective Care Paediatric Ear Nose And Throat OP - FUPs 1,092 1,086 1,080 1,073 1,066105 Elective Care Paediatric Ear Nose And Throat OP - Proc First 268 266 265 263 261106 Elective Care Paediatric Ear Nose And Throat OP - Proc FUPs 613 610 606 602 599107 Elective Care Paediatric Ophthalmology OP - First 1,005 1,000 995 989 982108 Elective Care Paediatric Ophthalmology OP - FUPs 628 624 621 617 613109 Elective Care Paediatric Ophthalmology OP - Proc First 3 3 3 3 3110 Elective Care Paediatric Ophthalmology OP - Proc FUPs 3 3 3 3 3111 Elective Care Paediatric Maxillo-Facial Surgery OP - FUPs 247 246 244 243 241112 Elective Care Clinical Psychology OP - First 180 178 176 174 172113 Elective Care Clinical Psychology OP - FUPs 405 401 396 391 386114 Elective Care Interventional Radiology / Diagnostic Imaging Day Cases 18 18 17 17 17115 Elective Care Interventional Radiology / Diagnostic Imaging Acute Block & Other non cost per c 0 0 0 0 0116 Elective Care not assigned PbR Drugs - excluding HIV 0 0 0 0 0117 Elective Care not assigned Acute Block & Other non cost per c 0 0 0 0 0118 Elective Care not assigned Community - all CCG / MBC / NCB 0 0 0 0 0119 Adult and Acute Accident & Emergency A&E 114,427 111,872 109,893 108,518 107,071120 Adult and Acute Accident & Emergency Elective IP 15 15 15 15 15121 Adult and Acute Accident & Emergency Non Elective IP 29 27 25 25 24122 Adult and Acute Accident & Emergency OP - First 1,885 1,863 1,839 1,815 1,790123 Adult and Acute Accident & Emergency OP - FUPs 301 298 294 290 286124 Adult and Acute General Medicine Elective IP 314 317 319 322 324125 Adult and Acute General Medicine Non Elective IP 13,827 12,745 12,133 12,026 11,943126 Adult and Acute General Medicine Delivery Episodes 3 3 3 3 3127 Adult and Acute General Medicine OP - First 2,443 2,416 2,389 2,360 2,330128 Adult and Acute General Medicine OP - FUPs 6,735 6,661 6,585 6,505 6,422129 Adult and Acute General Medicine OP - Proc First 80 79 78 77 76130 Adult and Acute General Medicine OP - Proc FUPs 59 59 58 57 56131 Adult and Acute General Medicine XBD 8,567 8,493 8,416 8,335 8,249132 Adult and Acute Gastroenterology Day Cases 4,143 4,090 4,036 3,980 3,921133 Adult and Acute Gastroenterology Elective IP 270 267 265 262 259134 Adult and Acute Gastroenterology Non Elective IP 9 8 8 7 7135 Adult and Acute Gastroenterology OP - First 3,197 3,162 3,126 3,088 3,049136 Adult and Acute Gastroenterology OP - FUPs 6,794 6,720 6,643 6,563 6,478137 Adult and Acute Gastroenterology OP - Proc FUPs 3 3 3 3 3138 Adult and Acute Gastroenterology XBD 127 126 125 124 123139 Adult and Acute Endocrinology Elective IP 7 7 7 7 7140 Adult and Acute Endocrinology OP - First 742 734 726 717 708141 Adult and Acute Endocrinology OP - FUPs 760 752 743 734 725142 Adult and Acute Endocrinology OP - Proc FUPs 50 50 49 49 48143 Adult and Acute Endocrinology XBD 9 9 9 9 9

144 Adult and Acute Clinical Haematology Day Cases 1,192 1,179 1,165 1,151 1,136145 Adult and Acute Clinical Haematology Elective IP 37 37 36 36 36146 Adult and Acute Clinical Haematology Non Elective IP 66 61 58 57 56147 Adult and Acute Clinical Haematology OP - First 682 676 671 664 658148 Adult and Acute Clinical Haematology OP - FUPs 5,166 5,123 5,078 5,031 4,981149 Adult and Acute Clinical Haematology OP - Proc FUPs 107 106 105 104 103150 Adult and Acute Clinical Haematology XBD 59 58 58 57 56151 Adult and Acute Diabetic Medicine Elective IP 4 4 4 4 4152 Adult and Acute Palliative Medicine OP - First 136 135 134 133 132153 Adult and Acute Palliative Medicine OP - FUPs 249 247 245 243 241154 Adult and Acute Cardiology Day Cases 177 175 173 170 168155 Adult and Acute Cardiology Elective IP 160 159 157 156 155156 Adult and Acute Cardiology Non Elective IP 801 740 704 694 683157 Adult and Acute Cardiology OP - First 12,284 12,179 12,068 11,952 11,828158 Adult and Acute Cardiology OP - FUPs 5,016 4,962 4,905 4,846 4,783159 Adult and Acute Cardiology OP - Proc First 1,260 1,246 1,232 1,217 1,201160 Adult and Acute Cardiology OP - Proc FUPs 1,789 1,770 1,750 1,729 1,706161 Adult and Acute Cardiology XBD 418 414 411 407 402162 Adult and Acute Paediatric Cardiology OP - First 15 15 15 15 15163 Adult and Acute Paediatric Cardiology OP - FUPs 71 71 71 70 70164 Adult and Acute Stroke Medicine OP - First 0 0 0 0 0165 Adult and Acute Stroke Medicine OP - FUPs 0 0 0 0 0166 Adult and Acute Transient Ischaemic Attack OP - First 769 761 752 743 733167 Adult and Acute Transient Ischaemic Attack OP - FUPs 0 0 0 0 0168 Adult and Acute Dermatology OP - First 3,322 3,284 3,244 3,202 3,159169 Adult and Acute Dermatology OP - FUPs 5,217 5,157 5,094 5,029 4,960170 Adult and Acute Dermatology OP - Proc First 834 824 814 803 792171 Adult and Acute Dermatology OP - Proc FUPs 3,272 3,234 3,195 3,154 3,111172 Adult and Acute Respiratory Medicine Day Cases -159 -168 -178 -188 -198173 Adult and Acute Respiratory Medicine Elective IP 128 127 125 124 123174 Adult and Acute Respiratory Medicine Non Elective IP 26 24 23 23 22175 Adult and Acute Respiratory Medicine OP - First 1,204 1,193 1,182 1,171 1,159176 Adult and Acute Respiratory Medicine OP - FUPs 4,694 4,643 4,590 4,534 4,476177 Adult and Acute Respiratory Medicine OP - Proc First 1,881 1,861 1,839 1,817 1,794178 Adult and Acute Respiratory Medicine OP - Proc FUPs 2,023 2,001 1,978 1,954 1,929179 Adult and Acute Respiratory Medicine XBD 30 29 29 29 29180 Adult and Acute Programmed Pulmonary Rehabilitation OP - First 145 143 142 140 138181 Adult and Acute Programmed Pulmonary Rehabilitation OP - FUPs 1,275 1,261 1,246 1,231 1,216182 Adult and Acute Geriatric Medicine Elective IP 56 56 56 56 57183 Adult and Acute Geriatric Medicine Non Elective IP 3,470 3,213 3,062 3,022 2,981184 Adult and Acute Geriatric Medicine OP - First 695 691 687 682 677185 Adult and Acute Geriatric Medicine OP - FUPs 576 573 569 565 561186 Adult and Acute Geriatric Medicine OP - Proc FUPs 6 6 6 6 6187 Adult and Acute Geriatric Medicine XBD 2,467 2,450 2,431 2,412 2,391188 Adult and Acute Clinical Oncology Non Elective IP 3 3 2 2 2189 Adult and Acute Clinical Oncology OP - First 730 721 712 702 692190 Adult and Acute Clinical Oncology OP - FUPs 4,531 4,476 4,419 4,360 4,298191 Adult and Acute Clinical Oncology OP - Proc First 3 3 3 3 3192 Adult and Acute Not Assigned Specialised Commissioning - ICD & 100 103 105 107 110193 Adult and Acute Not Assigned PbR Drugs - excluding HIV 0 0 0 0 0194 Adult and Acute Not Assigned Acute Block & Other non cost per c 0 0 0 0 0195 Adult and Acute Not Assigned Community - all CCG / MBC / NCB 0 0 0 0 0196 Family Care Paediatrics Day Cases 140 139 138 138 137197 Family Care Paediatrics Elective IP 125 127 129 131 133198 Family Care Paediatrics Non Elective IP 6,154 5,712 5,457 5,399 5,337199 Family Care Paediatrics OP - First 3,492 3,474 3,454 3,434 3,411200 Family Care Paediatrics OP - FUPs 4,241 4,219 4,196 4,171 4,143201 Family Care Paediatrics OP - Proc First 59 59 59 58 58202 Family Care Paediatrics OP - Proc FUPs 12 12 12 12 12203 Family Care Paediatrics XBD 196 195 194 193 192204 Family Care Paediatrics Healthy Babies 0 0 0 0 0205 Family Care Neonatology Non Elective IP 1,190 1,104 1,055 1,044 1,032206 Family Care Neonatology OP - First 277 275 274 272 270207 Family Care Neonatology OP - FUPs 886 882 877 872 866208 Family Care Neonatology OP - Proc First 0 0 0 0 0209 Family Care Neonatology XBD 54 53 53 53 52210 Family Care Neonatology Healthy Babies 0 0 0 0 0211 Family Care Obstetrics/Midwifery Non Elective IP 786 724 685 672 659212 Family Care Obstetrics/Midwifery Delivery Episodes 5,750 5,679 5,605 5,528 5,447213 Family Care Obstetrics/Midwifery OP - Proc FUPs 1,075 1,062 1,048 1,033 1,018214 Family Care Obstetrics/Midwifery Antenatal Pathways 6,267 6,189 6,108 6,024 5,937215 Family Care Obstetrics/Midwifery Postnatal Pathways 5,041 4,979 4,914 4,846 4,776216 Family Care Obstetrics/Midwifery XBD 570 563 556 548 540

217 Family Care Obstetrics/Midwifery Healthy Babies 0 0 0 0 0218 Family Care Obstetrics/Midwifery Non Delivery Spells in Maternity Pa 0 0 0 0 0219 Family Care Obstetrics/Midwifery OP in Maternity Pathway 0 0 0 0 0220 Family Care Gynaecology Day Cases 1,108 1,091 1,074 1,057 1,038221 Family Care Gynaecology Elective IP 599 590 581 572 563222 Family Care Gynaecology Non Elective IP 1,685 1,548 1,464 1,434 1,404223 Family Care Gynaecology Delivery Episodes 3 3 3 3 3224 Family Care Gynaecology OP - First 4,513 4,451 4,387 4,321 4,252225 Family Care Gynaecology OP - FUPs 8,235 8,123 8,006 7,886 7,760226 Family Care Gynaecology OP - Proc First 1,454 1,434 1,414 1,392 1,370227 Family Care Gynaecology OP - Proc FUPs 2,130 2,100 2,070 2,039 2,007228 Family Care Gynaecology XBD 30 29 29 28 28229 Family Care Gynaecology Non Delivery Spells in Maternity Pa 0 0 0 0 0230 Family Care Other TFC & not assigned OP - First 0 0 0 0 0231 Family Care Other TFC & not assigned OP - FUPs 0 0 0 0 0232 Family Care Other TFC & not assigned Specialised Commissioning - Neona 0 0 0 0 0233 Family Care Other TFC & not assigned PbR Drugs - excluding HIV 0 0 0 0 0234 Family Care Other TFC & not assigned Acute Block & Other non cost per c 0 0 0 0 0235 Family Care Other TFC & not assigned Community - all CCG / MBC / NCB 0 0 0 0 0236 Corporate Corporate PbR Drugs - excluding HIV 0 0 0 0 0237 Corporate Corporate CQUINS - achievement 0 0 0 0 0238 Corporate Corporate Acute Block & Other non cost per c 0 0 0 0 0239 Corporate Corporate Community - all CCG / MBC / NCB 0 0 0 0 0240 Corporate Corporate NEL Threshold (30% payment) 0 0 0 0 0241 Corporate Corporate Validations / coded after deadline 0 0 0 0 0242 Corporate Corporate Penalty - C Diff 0 0 0 0 0243 Corporate Corporate Penalty - Other incl Clinical Corresp 0 0 0 0 0244 Corporate Corporate Penalty - 18 weeks 0 0 0 0 0245 Corporate Corporate Penalty - Avoidable NEL readmissio 0 0 0 0 0

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ff TSenior Managers & Managers 52.80 51.17 49.61 48.13 46.73Medical Staff - Consultants 172.42 161.60 158.11 151.38 145.10Medical Staff - Other Career 37.23 34.89 34.14 32.68 31.33Medical Staff - Reg & Spr 80.01 74.99 73.37 70.25 67.34Medical Staff - Shos & Hos 139.00 130.28 127.47 122.04 116.98Medical Staff - Other Career 1.67 1.57 1.53 1.47 1.41Dental Staff - Consultants 0.24 0.23 0.22 0.21 0.20Dental Staff - Other Career 0.96 0.90 0.88 0.85 0.81Dental Staff - Reg & Spr 1.31 1.23 1.20 1.15 1.10Nurses - Qualified 1,707.36 1,618.43 1,568.41 1,496.16 1,427.95Nurses - Unqualified 18.95 17.96 17.41 16.61 15.85Scient, Therap & Tech Staff 388.44 370.98 362.21 348.48 335.65Scient & Prof Staff 165.20 157.77 154.04 148.20 142.75Prof & Tech Staff 153.05 146.17 142.71 137.30 132.25Other Scient, Therap & Tech 2.58 2.47 2.41 2.32 2.23Administrative & Clerical 799.68 755.50 722.02 684.35 648.78Hca & Other Support Staff 691.52 655.50 635.24 605.98 578.35Maintenance & Works Staff 41.01 41.01 41.01 41.01 41.01Non Nhs Staff (Agency Etc) 179.95 170.27 166.42 159.73 153.48Chairman & Non-Exes 6.00 6.00 6.00 6.00 6.00PAY 3.29 3.29 3.29 3.29 3.29

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D R An s - I a exp

Risk

Risk - Activity 0.5% lower than plan -1,269 -2,516 -3,741 -4,953 -6,151Mitigation - Take out relevant costs 1,041 2,063 3,067 4,061 5,044

al

n Risk - loss of activity due to Healthier Together 0 -7,500 -11,250 -15,000 -15,000Mitigation - Take out relevant costs 0 6,150 9,225 12,300 12,300

al

s Risk - 50% contractual improvements not delivered -2,150 -2,150 -2,150 -2,150 -2,150Mitigation - no direct mitigation 0 0 0 0 0

al

s Risk - 25% under delivery of cost improvements -4,049 -9,557 -13,891 -17,549 -21,182Mitigation - tactical controls 2,000 3,000 3,000 3,000 3,000

al

Risk - cost pressures 25% higher than forecast -1,950 -3,900 -5,850 -7,800 -9,750Mitigation - Bring forward CIPs 1,950 3,900 5,850 7,800 9,750

al

rall Residual impact -4,428 -10,510 -15,739 -20,290 -24,139Contingency Reserve 3,300 8,200 12,300 16,400 20,500Planned Surplus 1,600 3,100 4,600 5,100 5,500

al s

ive k

1 D de sk Anal s - Ca

k / M

re fo t Surplus available 472 317 371 49 651Working capital improvements 500 0 0 0 0Reduce capital programme 428 1,083 1,029 1,351 749

impact

loa / c n t e Reduce programme (Endoscopy / Learning Centre) 2,000 50 1,950 0 0Private finance re energy scheme 3,636 8,959 80 0 0

impact

IT l / c n t e Revert to do minimum option - capital 2,744 5,298 979 -129 -129Revert to do minimum option - revenue 28 890 1,095 957 957Delay capital programme 2,028 -992 -1,036 0 0

impact

al cas impact

Ca Fo t Planned Cash 1,000 0 0 973 2,401Planned change in cash 0 600 1,400 600 900Cash Downside -1,000 -600 -427 828 828

Ca

In r ri k

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Executive Summary

The committee received a paper at its June meeting which described the process to identify the long term efficiency plan. This paper provides a summary of the results of the process and makes recommendations as to how these should be treated in the long term financial plan (LTFP).

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Prepared by Simon Worthington Finance Director Presented by Simon Worthington

Finance Director

Agenda Item No 9

Meeting Finance & Investment Committee

Date 27th August 2013

Title Long Term Efficiency Strategy

Developing the Long Term Efficiency Plan – Update

1. Introduction

1.1 The committee received a paper at its June meeting which described the process to identify the long term efficiency plan. This paper provides a summary of the results of the process and makes recommendations as to how these should be treated in the long term financial plan (LTFP).

2. Process

2.1 The estimated requirement for efficiency of all types was set out in the June paper as £93.5m, being £73.1m to deal with the efficiency required in the base plan and £20.4m to deal with potential down side risks. The basis of the requirement is set out below:

2.2 The June paper described two products that were required for the long term plan.

Top down output - using benchmarking to identify the themes through which the Trust could potentially make £93.5m of efficiency savings over the next five years.

Bottom up process – describe in detail the savings plan for the first two years of the plan.

2.3 The top down process has been completed and the results are presented below. The bottom up process is not planned to be completed until the third week in September. Preliminary results are included in the paper.

2014/15 2015/16 2016/17 2017/18 2018/19 Total£m £m £m £m £m £m

Eliminate recurrent deficit 5.8 2.0 0.0 0.0 0.0 7.85 years efficency at 4% 10.9 10.9 10.9 10.9 10.9 54.5Local cost pressures 2.7 2.7 0.0 0.0 0.0 5.42% Surplus 0.0 2.7 2.7 0.0 0.0 5.4Total Improvement 19.4 18.3 13.6 10.9 10.9 73.1Total Improvement as % 7.1% 6.7% 5.0% 4.0% 4.0% 5.4%

Downside risk 1.5% pa 4.1 4.1 4.1 4.1 4.1 20.4

Total improvement opportunity required 93.5

3. Top Down Process Results

3.1 The Trust worked with CHKS to identify a suitable peer group to benchmark against. 40 medium sized acute Trusts were selected, eight of which have significant community services. A list of the organisations is attached as appendix one.

3.2 The main benchmarking approaches that have been used are as follows:

2011/12 accounts analysis Current staff in post using the national ESR database Productivity analysis conducted by CHKS on the 2012/13 HES data for the

benchmark group PBR income benchmarking performed by CAPITA

3.3 Accounts Benchmarking Results

3.3.1 The basis of this work is to look at the proportion of key elements of the Trust’s costs relative to its income. The table below shows the results, a breakdown for each Trust is provided at appendix two.

Staff Clinical Non Clin Finance TotalQuartile Costs Non Pay Non Pay Costs CostsBest Performer 56.7% 11.0% 7.2% 1.0% 95.0%Upper 60.7% 19.1% 10.6% 1.6% 98.8%Median 63.3% 21.4% 12.4% 1.9% 99.8%Lower 66.7% 22.6% 16.2% 2.9% 101.9%Worst Performer 70.9% 27.5% 30.3% 7.3% 120.9%

Bolton 12/13 73.6% 17.0% 13.1% 1.4% 105.1%

Move to:Median 10.3% 0.0% 0.6% 0.0%Upper quartile 12.8% 0.0% 2.4% 0.0%50% to Best 14.9% 3.0% 4.2% 0.2%Best 16.9% 6.1% 5.9% 0.4%

Financial Impact : £,000 £,000 £,000 £,000 £,000Median 28,200 0 1,800 0 30,000Upper quartile 35,200 0 6,700 0 41,90050% to Best 40,800 8,300 11,400 600 61,100Best 46,400 16,700 16,100 1,100 80,300

Costs as a % of income

3.3.2 The key point to note in respect of this is that Bolton FT is an outlier in respect of the costs of staff relative to income having the highest proportion of pay costs relative to income of any of the benchmark group. The Trust is higher than average cost on non-clinical non pay also.

3.3.3 To check for bias as a result of comparing with Trusts that do not have material community services the same analysis was run just against Trusts with community services and by taking out the income and costs of our community services. There wasn’t a material impact on the results.

3.3.4 On the face of it therefore very significant savings can be assumed if the Trust achieved median or above performance in these areas as demonstrated by the table above.

3.3.5 The Trust’s benchmarked position can only be because the

Trust is not receiving the income it should for the work it does Unit costs of staff and non-pay products is higher than average Productivity is lower than average

3.3.6 These reasons are explored in more detail below. The analysis presented is on the basis of the Trust achieving the upper quartile of performance in each area.

3.4 Income Issues

3.4.1 The work undertaken has identified £9.8m of income issues by year two of the plan. Due to the nature of some of the issues they will grow over time rising to £12.6m by year five.

PBR data quality – the CAPITA work has identified a number of areas where data quality improvements could lead to income improvements.

From our current contractual performance it is clear that £2m improvement could be gained through performing the contract better. For instance we are forecast to lose £1.6m in 2013/14 due to CDiF fines.

Year 1 Year 2 Year 3 Year 4 Year 5£,000 £,000 £,000 £,000 £,000

1) PBR Data quality 800 800 800 800 8002) Contractual performance 2,000 2,000 2,000 2,000 2,0003) Community Activity catch up 1,900 1,900 1,900 1,900 1,9004) Community Staffing ratio catch up 1,103 1,470 1,837 2,204 2,5715) Fixed Staffing Ratio other areas 1,629 2,173 2,717 3,261 3,8056) CQUINs to 100% 1,500 1,500 1,500 1,500 1,500

Total 8,932 9,843 10,754 11,665 12,576

The community contract is currently block. It is estimated that there is £1.9m increased activity over the last three years that has not been funded.

There are a number of areas (chiefly community and Midwifery) where the Trust has agreed to maintain fixed staffing ratios (e.g. the 1:28 Midwifery ratio) but is still being required to make a 4% efficiency each year. Over time this creates a substantial mismatch between the income received and the costs incurred (£3.6m by year two of the plan).

The Trust performs poorly in respect of CQuINs. Achieving 100% of the available income would improve the position by £1.5m per year.

3.5 Unit Costs of staff / non pay higher than average

3.5.1 The Trust’s staffing levels have been compared to those in the benchmarking group using the national ESR database. The agenda for change grade mix analysis that has been completed shows that the Trust is an outlier against the benchmark group for grade mix. The Trust is £4.8m more expensive than the median position, £9.1m of savings could be achieved if the Trust moved to the upper quartile position as demonstrated by the table below:

3.5.2 A table showing what the Trust’s Agenda for Change costs would be if we adopted the grade mix of each Trust in the benchmark group is at appendix three.

3.5.3 We are also able to analyse the types of staff by staff groups. This shows that the Trust has 8% more nurses and staff supporting nurses than the comparator group but 3% less doctors (when compared against Trusts with substantial community services). The data table to support this is shown at appendix four.

3.5.4 In respect of non-clinical non pay costs the accounts analysis showed £1.8m by moving to the median and £6.7m potential for moving to the upper quartile. Known cost issues that would help substantiate this are:

Bolton U QT Bolton Diff Mid Employer Gross GradeBand WTE Split @ Mean WTE Point £ Cost £ Cost £ MixBand 1 75 6.7% 285 210 14,653 3,370 18,023 3,793,269Band 2 750 22.9% 975 225 15,851 3,646 19,497 4,383,691Band 3 515 11.3% 479 36 17,794 4,093 21,887 777,076Band 4 405 9.2% 390 15 20,638 4,747 25,385 376,772Band 5 1070 24.0% 1,022 48 24,799 5,704 30,503 1,476,996Band 6 760 14.6% 621 139 29,579 6,803 36,382 5,038,979Band 7 520 9.2% 389 131 35,563 8,179 43,742 5,730,472Band 8a 150 2.3% 99 51 43,822 10,079 53,901 2,761,785Band 8b 50 0.9% 38 12 52,235 12,014 64,249 778,026Band 8c 15 0.3% 15 0 61,799 14,214 76,013 11,500Band 8d 10 0.2% 6 4 74,089 17,040 91,129 322,114Band 10 0 0.0% 0 0 89,640 20,617 110,257 0

4320 101.7% 4,320 9,096,762

The Trust has had abnormally high consultancy costs in the recent past – peaking at £3.5m in 2012/13.

Utilities costs are higher than necessary due to outdated systems and ineffective space utilisation – savings of £1m+ could be achieved.

The Trust’s IT infrastructure is not optimized to reduce establishment costs.

The Trust’s CNST contributions would be reduced if Level 3 Risk Management standards could be achieved.

3.6 Productivity

3.6.1 The following table identifies the value of potential productivity improvements that have been identified through benchmarking and other work on productivity.

3.6.2 The CHKS looks at a number of common productivity indicators for the benchmark group. A summary of the results is at appendix five.

3.6.3 For areas such as medical staff, theatres, pathology, radiology, therapies and divisional management estimates have been in conjunction with the Chief Operating officer which equate to 3% of pay costs each year.

3.6.4 The community analysis is derived from the community services financial strategy which is presented to the committee under separate cover.

Basis Item £,000CHKS 1 ALOS to upper quartile 3,000CHKS 2 30 Day Readmission to upper quartile 500CHKS 3 Day case rates to upper quartile 100CHKS 4 Outpatient procedures to upper quartile 400CHKS 5 Outpatient DNA Rates 400CCO 6 Acute staff productivity Yr 1 2,200CCO 7 Acute staff productivity Yr 2 2,200Com 8 Community Management costs 600Com 9 Community IT Travel scheduling 1,200Com 10 Community IT Record keeping 1,100Com 11 Community Utilisation 700Com 12 Community Service Priority Review 400DoF 13 Corporate Consultancy 1,200DoF 14 Corporate Priority review 800DoF 15 Corporate Staff Yr 1 @ 6.5% 1,000DoF 16 Corporate Staff Yr 2 @ 5% 800HRD 17 Sickness rate Yr 1 300HRD 18 Sickness rate Yr 2 300HRD 19 Pay reform increments 500

Total 17,700

3.6.5 The corporate staffing costs estimates are derived from analysis and benchmarking of the corporate functions performed by the Finance Director.

3.6.6 The potential gains on sickness and pay reform have been developed in conjunction with the Director of HR. It should be noted that the sickness estimates are supported by Better Care Better Value indicators for this area.

3.6.7 Overall £17.7m of productivity improvements are identified.

3.7 Overall conclusions from the top down process

3.7.1 Based on the above the £42m of improvements can be substantiated for inclusion in the early years of plan.

3.7.2 By extending the analysis to assume achievement of 50% of the difference between the upper quartile and the best performer in each category a further £23.5m of improvement can be assumed.

3.7.3 It is normal in analysis of this type to assume that the overall level of efficiency in the NHS provider sector will improve i.e. that the benchmark becomes a “moving target”. By assuming 2.2% improvement in the provider sector generally a further £30m improvement can be assumed over the life of the plan.

3.7.4 Appendix six shows the total assumed improvements mapped out over the five years of the plan.

3.7.5 It should be noted that at this stage the efficiency plan assumes a static turnover over the five year period. The plan will be adjusted to account for changes in turnover over the life of the plan when the relevant modelling wok has been completed.

3.7.6 This plan is consistent with the strategic configuration work Deloitte have been doing on behalf of the Trust. The reconfiguration process is one way of “cashing” the benefits forecast in the analysis. If a particular specialty is not affected by reconfiguration then the benefits would be cashed through normal service improvement methods.

4. Bottom up process

4.1 The bottom up process is focused on getting the first two years of the plan to the point where the Board can have reasonable assurance that the improvements can be delivered. To evidence this the following will be produced for each element of the plan

Project Initiation Document Clinical Risk Assessment

4.2 The preliminary results of the bottom up exercise are contained in the specific improvements identified in years one and two of the plan shown at appendix six.

5. Conclusion

5.1 Overall good progress has been made towards identifying a fit for purpose long term efficiency plan. It is recommended that the committee

i) Critically reviews the information provided and assumptions made

ii) Require any changes deemed necessary after this review

Appendices

1. Trusts included in peer group 2. Accounts review detail 3. Agenda for change costs at individual peer group mixes 4. Comparison of staff groups 5. CHKS Benchmark summary 6. Draft five year efficiency plan

Peer Group Summary Appendix 1Trusts Peer Type Trust TypeBARNET AND CHASE FARM HOSPITALS NHS TRUST Medium Peer Std TrustBASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Medium Peer FTBLACKPOOL TEACHING HOSPITALS NHS FOUNDATION TRUST Medium Peer FTBUCKINGHAMSHIRE HEALTHCARE NHS TRUST Medium & Comm Peer Std TrustCALDERDALE AND HUDDERSFIELD NHS FOUNDATION TRUST Medium & Comm Peer FTCITY HOSPITALS SUNDERLAND NHS FOUNDATION TRUST Medium Peer FTCOLCHESTER HOSPITAL UNIVERSITY NHS FOUNDATION TRUST Medium Peer FTCOUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST Medium Peer FTEAST AND NORTH HERTFORDSHIRE NHS TRUST Medium Peer Std TrustEPSOM AND ST HELIER UNIVERSITY HOSPITALS NHS TRUST Medium Peer Std TrustGREAT WESTERN HOSPITALS NHS FOUNDATION TRUST Medium & Comm Peer FTHAMPSHIRE HOSPITALS NHS FOUNDATION TRUST Medium Peer FTLUTON AND DUNSTABLE HOSPITAL NHS FOUNDATION TRUST Medium Peer FTMAIDSTONE AND TUNBRIDGE WELLS NHS TRUST Medium Peer Std TrustMEDWAY NHS FOUNDATION TRUST Medium Peer FTNORTH TEES AND HARTLEPOOL NHS FOUNDATION TRUST Medium & Comm Peer FTNORTH WEST LONDON HOSPITALS NHS TRUST Medium Peer Std TrustNORTHAMPTON GENERAL HOSPITAL NHS TRUST Medium Peer Std TrustNORTHERN DEVON HEALTHCARE NHS TRUST Medium Peer Std TrustNORTHERN LINCOLNSHIRE AND GOOLE HOSPITALS NHS FOUNDATION TRUST Medium Peer FTPETERBOROUGH AND STAMFORD HOSPITALS NHS FOUNDATION TRUST Medium Peer FTROYAL BERKSHIRE NHS FOUNDATION TRUST Medium Peer FTROYAL CORNWALL HOSPITALS NHS TRUST Medium Peer Std TrustROYAL UNITED HOSPITAL BATH NHS TRUST Medium Peer Std TrustSALFORD ROYAL NHS FOUNDATION TRUST Medium & Comm Peer FTSANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST Medium & Comm Peer Std TrustSHERWOOD FOREST HOSPITALS NHS FOUNDATION TRUST Medium Peer FTSHREWSBURY AND TELFORD HOSPITAL NHS TRUST Medium Peer Std TrustST HELENS AND KNOWSLEY HOSPITALS NHS TRUST Medium Peer Std TrustSTOCKPORT NHS FOUNDATION TRUST Medium & Comm Peer FTSURREY AND SUSSEX HEALTHCARE NHS TRUST Medium Peer Std TrustTHE DUDLEY GROUP NHS FOUNDATION TRUST Medium Peer FTTHE ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NHS FOUNDATION TRUST Medium Peer FTTHE ROYAL WOLVERHAMPTON NHS TRUST Medium Peer Std TrustUNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST Medium Peer FTWARRINGTON AND HALTON HOSPITALS NHS FOUNDATION TRUST Medium Peer FTWEST HERTFORDSHIRE HOSPITALS NHS TRUST Medium Peer Std TrustWIRRAL UNIVERSITY TEACHING HOSPITAL NHS FOUNDATION TRUST Medium Peer FTWORCESTERSHIRE ACUTE HOSPITALS NHS TRUST Medium Peer Std Trust

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Executive Summary

To note the draft assumptions that underpin the community services element of the Long Term Financial Plan that the Trust is required to submit to Monitor by the end of September 2013.

Next steps/future actions

Discuss Receive Approve Note

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Prepared by Simon Worthington Finance Director Presented by Simon Worthington

Finance Director

Agenda Item No 10

Meeting Finance & Investment Committee

Date 27th August 2013

Title Long Term Financial Plan Development – Community Services

Bolton NHS Foundation Trust

Long Term Financial Plan Development – Community Services Draft

1. Introduction

1.1 Really effective community services are key to delivering the integrated service vision of allstakeholders in the Bolton health economy. There are a number of finance and contractingissues that need to be resolved to ensure that community services can deliver this vision asfollows:

There is an existing material deficit on the services

The block contract does not facilitate service shifts or recognise demand growth

Some service specifications are not consistent with tariff deflation assumptions

The opportunity for and impact of cost reductions required by tariff deflation are poorlyunderstood

1.2 The purpose of this paper is to set out the draft assumptions that underpin the communityservices element of the Long Term Financial Plan (LTFP) that the Trust is required to submitto Monitor by the end of September 2013. The assumptions describe the Trust’s proposedsolution to the issues identified in paragraph 1.1. It is intended that these assumptions arereviewed and agreed by the Trust and by Bolton CCG before being included in the finalversion of the plan.

1.3 The assumptions have been developed by the Trust Finance Director and the ProgrammeDirector for Community Integration (Helen Clarke). The assumptions are based on theinformation currently available. The potential for estimation risk is identified in eachelement described.

2. Summary results

2.1 The forecast deficit on the Trust’s community services for 2013/14 is £4.7m. This issubstantiated by the service line analysis attached at appendix two. The table below showsthe key bridging items that take this deficit to forecast sustainable surplus from 2015/16onwards.

Table 1 – Community services summary bridge analysis

2014/15 2015/16 2016/17 2017/18 2018/19£,000 £,000 £,000 £,000 £,000

1) Deficit / (Surplus) brought forward 4,672 334 417 515 4512) Resolve Historic Issues 3,003 0 0 0 03) Estimated Integration Investment 333 333 0 0 04) Tariff / generic inflation impact 2,157 2,274 2,323 2,331 2,3385) Activity impact 250 217 225 210 2006) CIP Impact 2,909 2,474 2,196 2,056 2,0487) Forecast for the year 334 417 515 451 361

3. Bridge analysis

3.1 The detailed bridge is shown at appendix one. The following table explains the various items.

Ref Item Explanation1) Brought forward

deficit£4.7m (8%) opening deficit is as per the service line analysis shown atappendix two. The forecast deficits / surpluses are explained by thebridging items in the analysis.

2) Resolve historicissues

Given the scale of the starting deficit decisive action is required to getthe service in recurrent balance as soon as possible.

2a) Activity catch up Value £1.9m

The service has been on block contract since 2011/12. No contractchanges have been made for general rises in activity although somespecific adjustments have been made.

The impact of activity of income is calculated with reference to thedemographic change that has occurred over the period less specificfunding that has been agreed. It is assumed that commissioners willfund this activity cost retrospectively.

The alternative to funding this activity increase would be to agreeservice reductions to the value of £1.9m

2b) Staffing ratio fundingcatch up

Value £1.1m

A number of service specifications require the Trust to maintain a fixedstaffing establishment. The Trust is not therefore able to realise the5% annual cost reductions that have been required from these servicesthrough the life of the contract. It is assumed that commissioners willfund this cost pressure retrospectively.

The calculation is shown at appendix three.

The alternative to funding this cost pressure would be to agree servicereductions to the value of £1.9m.

2c)and2d)

IT Infrastructuretransfer

Due to the change to from PCT to CCG IT network costs associatedwith the community services are now being incurred by the Trust. TheCCG has the funding for these costs and it is assumed that this fundingwill be allocated to the Trust.

2e)and2f)

Impact ofcommunity ITinvestment

The IT infrastructure in the community is not fit for purpose and doesnot integrate with hospital systems. Neither the integration agendanor the productive time cost improvements identified below aredeliverable with the current IT infrastructure. Investment of £1.9m isrequired to resolve this issue. It is assumed commissioners will fundthis as it is critical to the patch service strategy.

3) Estimatedintegrationinvestment

This is the requirement to invest in community services in order toavoid unnecessary admissions / attendances.

The CCG have submitted assumptions to the Healthier Togetherprogramme showing £6.3m of acute activity being prevented as aresult of community integration work.

The relationship between community investment and reducedadmissions has not yet been established/ agreed. For the time being£3m of community activity is assumed to be required.

It is assumed that this activity increase will trigger direct and indirectcosts but no overheads so that a small margin is made on the activity.

4) Tariff / genericinflation impact

It is assumed that the national efficiency requirement will be 4% forthe life of the plan, this is made up of 1.3% tariff reduction and 2.7%unfunded cost pressures.

It is assumed that if service specifications require fixed staffingnumbers that the relevant efficiency requirement will be made goodby commissioners. This reduces the efficiency requirement by up to0.5% per year.

5) Activity impact The service cost base has been analysed by the age range of the clientgroup. Office of National Statistics population forecasts have beenused to estimate likely changes in demand – estimated as 7.2% overthe life of the plan.

An allowance has also been made for the predicted significant rise inspecialist care packages required giving a final prediction of 8.4%demand growth over the life of the plan.

It is assumed that this will be funded through a variable contract at fullcost. The activity increase is assumed only to trigger direct and indirectcost so a small margin is made on the activity.

6) Cost improvementImpact

The potential for cost improvements has been estimated through theuse of existing cost information and the estimates of productive timemade based on the knowledge and experience of the programmedirector. These estimates are reasonable at the strategic level butsignificant work is required to bring them to the point of deliverableoperational plan.

6a) CIP Managementcost

The total management cost for the service is estimated at £3m. It isassumed that this can be reduced by 20% in the first year of the planby amalgamating a number of fragmented services into generic servicegroups.

6b) CIP Travelscheduling

Staff in services that require home visits are estimated to spend 20% oftheir time travelling. It is assumed that an effective scheduling systemcombined with a revised policy on which patients are entitled to homevisits could reduce this by 25% giving a saving of £1.2m recurrently.

This saving depends on the enhancement of the community ITinfrastructure. It is assumed that the saving will begin to accrue inquarter four of the first year of the plan and be fully realised by yearthree.

6c) CIP Record Keeping Due to the poor nature of the community IT infrastructure some staffspend up to 10% of their time maintaining the necessary records oftheir clinical activity. The right IT could improve this by 50% giving asaving of £1.1m recurrently.

This saving depends on the enhancement of the community ITinfrastructure. It is assumed that the saving will begin to accrue inquarter four of the first year of the plan and be fully realised by yearthree.

6d) CIP Utilisation There are a small number of services with known utilisation issues.These issues are assumed to be addressed in year one byamalgamating these services with others groupings. £0.7m savings areanticipated.

6e) CIP Sickness rate A 20% improvement in sickness rate is assumed to accrue over the firstthree years of the plan. This to be driven by improved sicknessmanagement. £0.4m is assumed recurrently after three years.

6f) CIP Grade mix A grade mix opportunity of £750k is estimated. This will be realisedthrough redesigning the team structures giving a reduced requirementfor band 8a and band 7 nurses.

This saving will mainly crystalize in year five because of the assumedlength of pay protection.

6g) CIP Indirect costs It is assumed that 2% per year productive time / other improvementscan be delivered in indirect costs.

6h) CIP Overheads 5% per year overhead reduction is assumed to be deliverable over thelife of the plan.

6i) CIP – Service priorityreview

There is anecdotal evidence to suggest that the commissioners wouldsupport the cessation of a small number of services of limited clinicalvalue. It is assumed that £400k of direct cost savings could be madefrom this and the income retained.

6j) CIP – to be identified It assumed that an additional £2.7m of productive time improvementswill be identified once robust information systems are in place. Theseimprovements are assumed to be delivered over the last three years ofthe plan.

4. Conclusion

4.1 The plan described is one answer to the question of securing clinically effective andfinancially viable community services in Bolton. These assumptions should be reviewed andchallenged by all stakeholders so that the final plan is acceptable to all. This process must beconcluded by the 6th December.

Appendices

1. Bridge analysis2. Community service line analysis including productive time estimates3. Staffing ratio calculation4. Demand growth estimate5. Grade mix assumption6. Management cost assumption

1. BFT Community Services Draft Five Year Financial Plan Bridge Analysis2014/15 2015/16 2016/17 2017/18 2018/19

£,000 £,000 £,000 £,000 £,0001) Deficit / (Surplus) brought forward 4,672 334 417 515 451

as % of income 8.0% 0.5% 0.6% 0.8% 0.7%

2) Resolve Historic Issues £,000 £,000 £,000 £,000 £,000a Activity Catch Up 1,900 0 0 0 0b Staffing ratio funding catch up 1,103 0 0 0 0c IT Infrastructure transfer 480 0 0 0 0d IT Infrastructure transfer 480 0 0 0 0e Funding Impact of £1.9m IT invest 380 0 0 0 0f Capital Charges Impact of £1.9m IT invest 380 0 0 0 0

Total 3,003 0 0 0 0as % of income 5.1% 0.0% 0.0% 0.0% 0.0%

3) Estimated Integration Investment £,000 £,000 £,000 £,000 £,000a Activity demographic change 1,500 1,500 0 0 0b Direct Cost Activity demographic change 913 913 0 0 0c Indirect Cost Activity demographic change 254 254 0 0 0

Total 333 333 0 0 0as % of income 0.6% 0.5% 0.0% 0.0% 0.0%

4) Tariff / generic inflation impact £,000 £,000 £,000 £,000 £,000a Tariff Deflation @ 1.3% 764 842 868 874 879b In year staffing ratio funding 319 327 336 345 355c Direct Costs Generic Inflation @ 2.7% 1,063 1,078 1,103 1,112 1,124d Indirect Costs Generic Inflation @ 2.7% 263 277 290 297 303e Overhead Costs Generic Inflation @ 2.7% 326 332 324 317 309f Capital Charges @2.7% 60 72 74 76 78

Total 2,157 2,274 2,323 2,331 2,338as % of income 3.7% 3.5% 3.5% 3.5% 3.5%

5) Activity impact £,000 £,000 £,000 £,000 £,000a Activity demographic change 1,125 977 1,011 946 902b Direct Cost Activity demographic change 684 594 615 575 549c Indirect Cost Activity demographic change 190 165 171 160 153

Total 250 217 225 210 200as % of income 0.4% 0.3% 0.3% 0.3% 0.3%

6) CIP Impact £,000 £,000 £,000 £,000 £,000a CIP Management costs 575 0 0 0 0b CIP IT Travel scheduling 144 754 300 0 0c CIP IT Record keeping 113 721 300 0 0d CIP Utilisation 697 0 0 0 0e CIP Sickness rate 131 131 131 0 0f CIP Grade mix 50 50 50 50 550g CIP Indirect costs @ 2% 195 205 215 220 225h CIP Overheads @ 5% 604 614 600 586 573i CIP Service Priority Review 400 0 0 0 0j CIP To be identified (productive time) 0 0 600 1,200 700

Total 2,909 2,474 2,196 2,056 2,048as % of income 5.0% 3.8% 3.3% 3.1% 3.0%

7) Forecast for the year £,000 £,000 £,000 £,000 £,000a Income 64,777 66,739 67,218 67,635 68,012b Direct Costs 39,923 40,853 41,190 41,628 42,050c Indirect Costs 10,252 10,743 10,989 11,226 11,457d Overheads 12,282 12,000 11,724 11,455 11,191e Cap Charges 2,654 2,726 2,800 2,876 2,954f Closing Deficit / (Surplus) 334 417 515 451 361

as % of income 0.5% 0.6% 0.8% 0.7% 0.5%

Appendix 1

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4. BFT Long Term Financial Plan Community Services Demand Growth Working Appendix 4

2010 based Subnational Population Projections

Quinary age groups, Persons

Figures in thousands (to one decimal place)Source : ONS

CODE AREA AGE GROUP 2013 2014 2015 2016 2017 2018E08000001 Bolton 0 4 20 20.4 20.7 20.9 21 21

Bolton 5 9 18.1 18.6 19 19.4 19.8 20.2Bolton 10 14 16.1 16.3 16.5 17.1 17.6 18.3Bolton 15 19 16.8 16.6 16.5 16.1 15.8 15.6Bolton 20 24 18.1 17.9 17.5 17.2 17 16.8Bolton 25 29 19.7 20.2 20.6 20.8 21.1 21Bolton 30 34 17.5 18.1 18.7 19.3 20 20.6Bolton 35 39 16.3 16.2 16.5 16.9 17.5 18Bolton 40 44 19.7 19.1 18.6 17.8 17 16.4Bolton 45 49 20.1 20.1 19.8 19.8 19.7 19.5Bolton 50 54 18.1 18.7 19.2 19.6 19.7 19.7Bolton 55 59 15.4 15.7 16.1 16.6 17 17.5Bolton 60 64 14.8 14.5 14.2 14.2 14.4 14.6Bolton 65 69 15 15.3 15.5 15.3 14.5 13.9Bolton 70 74 11.1 11.4 11.7 12.1 13.2 13.7Bolton 75 79 8.2 8.6 8.8 9 9.2 9.6Bolton 80 84 6 6 6.1 6.2 6.3 6.5Bolton 85 89 3.7 3.8 3.8 3.9 3.9 4Bolton 90+ 2 2 2.1 2.2 2.3 2.3Bolton All ages 276.8 279.4 281.9 284.4 286.9 289.4

Communit groupings summary 2013 2014 2015 2016 2017 2018,000 ,000 ,000 ,000 ,000 ,000

Child 54.2 55.3 56.2 57.4 58.4 59.5All Ages 276.8 279.4 281.9 284.4 286.9 289.4Adult 18 50 128.2 128.2 128.2 127.9 128.1 127.9Adult >50 94.3 96 97.5 99.1 100.5 101.8Adult >65 46 47.1 48 48.7 49.4 50

Forecast cost of delivering 2013 2014 2015 2016 2017 2018£,000 £,000 £,000 £,000 £,000 £,000

Child 14,744 15,043 15,288 15,615 15,887 16,186All Ages 4,796 4,842 4,885 4,928 4,972 5,015Adult 18 50 7,977 7,977 7,977 7,958 7,971 7,958Adult >50 19,743 20,099 20,413 20,748 21,042 21,314Adult >65 11,474 11,748 11,973 12,147 12,322 12,471Total 58,735 59,709 60,536 61,397 62,192 62,944Expecetd increase 975 827 861 796 752Specialist care packages 150 150 150 150 150Total increase 1,125 977 1,011 946 902

4,959

Table 2a: Local authorities and higher administrative areas within North East, North West and Yorkshire and The Humber

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Tackling the Issues that affect the health of the town

Appendix H.26

Telephone 01204 462030 St Peter’s HouseSilverwell Street

Bolton BL1 1PP

Fax: 01204 462048 Our Ref: SL/JM Your Ref: Date: 30th September 2013 E-Mail: [email protected] Dr J Bene Interim Chief Executive Bolton Hospital NHS Trust Royal Bolton Hospital Minerva Road, Farnworth Bolton BL4 0JR Dear Jackie Bolton FT 5 Year Plan I understand that your 5 year plan is due to be submitted to Monitor on 30 September and that it would be helpful to include a commissioner perspective. I have already had a short phone call with Kate Sutherland from Monitor and reflected our position as follows : I know that Annette Walker and Simon Worthington have worked closely in recent weeks to ensure that the income projections include realistic assumptions in relation to key strategic issues such as community services, integration, efficiency assumptions and the QIPP challenge. The income plans are consistent with the NHS economic and financial environment of flat real growth over the next 5 years and the CCG’s vision to invest in primary and community services. The income projections represent the best information the FT have at this point. The peak in income shown in 2015/16 does present an affordability challenge to the CCG and we will need to look at options to manage this including potentially decommissioning certain community services. The CCG has recognised the impact of tariff deflation on community services and that investment is needed to support these services in the short term whilst further work on service specifications, integration and productivity is undertaken. On Friday, the CCG Board approved transitional funding of £1.2m to support community services from any further reductions whilst we undertake a joint community services review. Yours sincerely

Susan Long Chief Officer NHS Bolton Clinical Commissioning Group

Documents

CONTENTS · CONTENTS 2 AMS/KT/601v8 08.10.13 8. Enabling Strategies 57 8.1 Estate Strategy – The Challenge 58 8.2 Informatics Strategy 65 8.3 Workforce Strategy 67 8.4 “Back Office”