BOARD OF DIRECTORS
MEETING IN PUBLIC
27 March 2014
PAPERS
Board of Directors’ Meeting Part I in Public
27 March 2014
09.00 The Education Centre, Birmingham Children’s Hospital
AGENDA
Item
No.
14.43
14.44
14.45
14.46
14.47
14.48
14.49
14.50
14.51
14.52
Item
Apologies for absence
Declarations of interest
Minutes of public Board meeting 27 February, 2014
Outcome
Note
Note
Approve
Matters arising from public Board meeting 27 February Note
2014
Chairman’s Report
Note
Chief Executive’s Report
Note
Strategy
Our Nursing Workforce.
Note &
Michelle McLoughlin, Chief Nurse
Approve
Next Generation Project
Note &
Sarah-Jane Marsh, Chief Executive
Approve
Monitor Operational Plan 2014/15 – 2015/16
Note &
David Melbourne Chief Finance Officer & Deputy Chief Approve
Executive and Matthew Boazman, Director of Strategy and
Planning
10.45 Break 10 mins
Quality & Resources
Quality Report 2013-14 – Local Indicators Vin Diwakar, Note &
Chief Medical Officer
Approve
Time
Allocated
time
09.00
09.00
05 mins
Report type
Verbal
Verbal
Enclosure 01
Verbal
09.05
09.10
05 mins
20 mins
Verbal
Verbal
09.30
30 mins
Enclosure 02
10.00
30 mins
Presentation
10.30
15 mins
Enclosure 03
10.55
20 mins
Enclosure 04
14.53
Quality Report - Vin Diwakar, Chief Medical Officer and Note &
Michelle McLoughlin, Chief Nurse
Approve
11.15
10 mins
Enclosure 05
14.54
Performance Report - David Melbourne Chief Finance
Officer & Deputy Chief Executive
Resources Report - David Melbourne Chief Finance Officer
& Deputy Chief Executive, Phil Foster, Director of Finance &
Procurement and Theresa Nelson, Chief Officer for
Workforce Development.
11.25
10 mins
Enclosure 06
11.35
10 mins
Enclosure 07
11.45
05 mins
None
14.55
Note &
Approve
Note &
Approve
Any other business
14.56
Questions from members of the public
Part II of this meeting of the Board of Directors will be held in private, as the information to be discussed is exempt from
public disclosure under the Freedom of Information Act 2000.
Next meeting of the Board of Directors: 30 April 2014, Education Centre, BCH
UNCONFIRMED
Item 14.45
Enc 01
BOARD OF DIRECTORS MEETING
Minutes of the meeting held in public on 27 February 2014 at 09.00
in the Education Centre, Birmingham Children’s Hospital
Present
Attending
Ref.
14.29
14.30
14.31
14.32
14.33
Keith Lester
Sarah-Jane Marsh
Tim Atack
Vin Diwakar
Judy Green
Jon Glasby
Colin Horwath
Michelle McLoughlin
David Melbourne
Theresa Nelson
Roger Pearce
Elaine Simpson
KL
SJM
TA
VDi
JAG
JG
CH
MM
DM
TN
RP
ES
Interim Chairman
Chief Executive Officer
Chief Operating Officer
Chief Medical Officer
Non-Executive Director
Non-Executive Director
Non-Executive Director
Chief Nursing Officer
Deputy CEO and Chief Finance Officer
Chief Officer for Workforce Development
Non Executive Director
Non Executive Director
Deborah Bannister
Matthew Boazman
Christine Braddock
Claire Burden
Simon Crooks
Phil Foster
DB
MB
CB
CBN
SC
PF
Interim Company Secretary
Director of Strategy and Planning
Chairman elect
Deputy Chief Operating Officer
Executive Office Manager (minutes)
Director of Finance and Procurement
Item
Apologies
There were no apologies for absence.
Declarations of Interest
None
Minutes of the Board meeting held in public on 30 January 2014
The minutes were agreed as an accurate record.
Matters arising from the Board meeting held in public on 30 January 2014
There were no matters arising not covered by the agenda.
Chairman’s Report
Judy Green
This would be the last meeting that JAG would attend pending her retirement at the end of this
month. The Board joined with KL in expressing their thanks and appreciation for the dedicated
service and time given by JAG to the Trust over the last eight years
Governors
DB was now redrafting the Trust constitution to incorporate changes arising from the Health &
Social Care Act 2012 but also to consider options as to the number and breakdown of Governor
Page 1 of 8
Action
UNCONFIRMED
Item 14.45
Ref.
Enc 01
Item
particularly following the demise of PCT’s, leaving a number of partner governor vacancies.
In addition a KPMG questionnaire had been circulated to governors seeking details as to how
effective they thought their role was.
SJM expressed the importance of encouraging greater involvement from all governors, not just
the more outspoken members, as staff governors in particular have a lot to give.
In addition the Trust membership needs to be reviewed - how to arrest the decline and
increase membership was important, together with improved engagement.
TN referred to the four staff governors and suggested staff should be encouraged to engage
and become more involved with their representatives.
The Board noted the verbal report
14.34
Chief Executive’s Report
SJM reported verbally as follows:
The outcome of a Trauma Peer Review carried out at the Trust had been extremely
positive. The reviewers felt they had learnt a lot from the Trust that they could go on to
share as best practice. The only suggestion made was to be wary of complacency and to
continue to strive to improve.
A Deanery visit focussing on neuro and orthopaedic surgical training had also received
excellent feedback. An impressive cultural change in respect of junior doctors had been
noted as well as improved communication. Again the only concern had been the danger
of losing momentum.
The staff survey results had just been received and were now being analysed. They
would be considered initially by the Quality Committee before being presented to
Board. All five engagement indicators had improved. Key messages and concerns were
related to levels of stress and long hours. It was hoped that the forthcoming Intent to
listen sessions would hopefully provide the opportunity to discuss these concerns in
more detail.
SJM was hosting ‘tea parties’ recognising excellent team performance, the latest one
had been in the KIDS service.
SJM and MM had enjoyed an excellent session with the Trust’s YPAG, who had been
asked to describe what constituted excellent care. Compassion was seen as the core
requirement, but the ability to “remove worry” was also seen as a vital element. A
presentation from YPAG was expected at the March Board meeting..
NHS Change Day is Monday 3rd March. Over 80 members of staff had joined SJM in
pledging to support the power of storytelling, which in turn was attracting media
coverage.
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Action
UNCONFIRMED
Item 14.45
Ref.
Enc 01
Item
SJM was attending the NHS EXPO event in Manchester to join a discussion on care data.
The Board noted the verbal report
STRATEGY
14.35
Fundraising strategy – Review and Update
LM presented a review of the Trust’s fundraising strategy and emphasised the importance of
the Trust establishing a strategy that was fully integrated with the Trusts long term plans.
Fundraising is often the most visible part of the organisation and therefore cannot work in
isolation. This was specifically important with the decision to pursue the new hospital project.
A number of core objectives were highlighted, the principal one being to raise £10 million per
annum by 2017/18. Whilst significant growth was noted in recent years, LM stated that there
were key building blocks that must be put in place now to establish key networks/partnerships
that will be essential in the future.
To achieve this, the reliance on public fundraising via one large local capital appeal had to
change in favour of supporting the hospital as whole and having a variety of projects on offer.
Individuals, corporates and trusts are all looking for something different and we need to get
more sophisticated by having the right proposition for each market.
Another key objective was the need to invest in new technology to ensure prospective donors
were being approached in the most effective way and the new database will strengthen the
strategic overview functions.
Furthermore LM wished to highlight that in order to deliver the fundraising strategy it was vital
that the brand awareness of the Hospital was strengthened, which in turn would benefit long
term fundraising strategies. The importance of promoting the Trust from a local, regional
provider towards more of a Midlands and national profile would certainly enhance donations.
In summary LM outlined critical areas to achieve planned growth. Firstly, a core proposition for
individuals must be created, explaining why they should support the charity ahead of others,
which will grow our individual giving income streams and in turn create more sustainable
funding.
A portfolio of fundraising projects must also be created. Over the next three years we plan to
grow major gift and trust fundraising income by 300% and currently we don’t have a future
pipeline. LM asked all to consider what process could be put in place to ensure we’re not
missing opportunities. In addition, LM stated that current reviews and discussions in regards to
fundraising systems were taking place to ensure that our operations were centralised and fit for
Page 3 of 8
Action
UNCONFIRMED
Item 14.45
Ref.
Enc 01
Item
purpose to cope with predicted future volumes.
LM highlighted the growing competitiveness of the fundraising market and emphasised the
need to embrace a culture of fundraising within the hospital. It’s important for all staff to be
able to articulate why fundraising approaches are being made and secondly to explain where
their donations were going and for what reason.
Discussion followed on the how the fundraising strategy was perceived; DM indicated that the
philanthropy team at Barclays Wealth had suggested our targets were not ambitious enough,
whilst JG added that there was still a wide spread misconception that the NHS still relied on
central funding and didn’t need charitable support. To counter this MB suggested the
fundraising message could be strengthened by emphasising the need and cost of medical
research.
VDi referred to the strong market penetration Great Ormond Street Hospital had achieved. SJM
explained that this was due to the huge marketing machine their fundraising team enjoyed, but
at the same time this highlighted the need for BCH to move away from being seen as a local
provider, positioning in the fundraising market was vital. CH agreed and added that it was
important to raise the BCH brand awareness.
CB stressed the importance of promoting the fundraising brand in the culture of BCH – job
specifications should have the message and importance embedded within them. Secondly
would our ambitions be restricted by the proposed figure of £10m and whether we should have
a silent target? The message would also benefit from including details of how fundraising had
benefited the Trust – lives saved, the impact on patients.
MM asked how going forward we would work in partnership with BCH Charities and
emphasised the importance of working with them.
The Board accepted the report and agreed to the outline proposals recommended.
14.36
Developing our Transformation – the EQUIP work stream
CBN introduced a presentation on the Trust’s proposed Enabling Quality Improvement
Programme (EQuIP). The EQuIP has been designed to oversee the planned transformation of
services provided by the Trust.
The transformation programme will provide dedicated project management support directly
into front line services. The primary aim of the transformation programme is to deduce waste
whilst maintaining and where possible improving quality in order to generate capacity to work
differently. What individual services chose to do with any realised capacity from transformation
is for each Directorate to determine.
The transformation programme will be accountable to Senior Leadership Team (SLT). The
transformation programme will be developed through two forums, a clinical and patient forum.
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Action
UNCONFIRMED
Item 14.45
Ref.
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Item
Operational initiatives will be reviewed and prioritised by the clinical and patient forums in
order that the transformation programme concentrates it's efforts to areas of greatest need. In
the year 1 four work streams have been identified; Theatre/Surgical, Outpatients, Pre
admission and Drug management. It will be the role of the clinical and patient forums to
prioritise initiates within these work streams.
The transformation programme will be fully supported by a Programme Management Office
(PMO). The PMO will ensure that all transformation work streams are sufficiently worked up in
terms of milestones, actions, risks and outcomes. The PMO is an essential component of
delivering the transformation agenda.
To pump prime the transformation programme CBN shared that there is a business case for the
Board to consider proposing a fixed term partnership with an engineering redesign company,
Newton Europe (“Newton”). Newton offer expert skills in process engineering and their
support would accelerate the redesign of services within the surgical and outpatients work
streams. A piece of preliminary work completed by Newton identified a number of areas that
the transformation programme could focus on to improve patient flow. Newton worked
alongside our clinicians and our clinicians impressed by the Newton team analysis and their
approach; feedback was consistently that Newton colleagues listened and adapted their models
accordingly.
TA emphasised the importance of this and the wider engagement with clinicians. Initial
discussions had already taken place and feedback was encouraging. VDi supported the
approach but emphasised the importance of clinicians been part of the operation.
The Board stressed the importance of communication in this process: the approach and
development of the transformation had to be done in partnership and not in isolation. SJM
agreed – all projects had to fit together to avoid mixed or confusing messages to staff.
CB expressed a degree of confusion. She felt the message was not clear enough and would be
difficult to promote and ensure engagement.
In conclusion the first clinicians meeting had taken place and the first patient’s forum would be
held in April. The next steps would be Board approval to appoint Newton who would enable the
operational change process and for the Board to invest in a PMO to manage the
transformation.
The Board accepted the report and agreed to the outline proposals recommended
QUALITY & RESOURCES
14.37
Quality Report
VD introduced the report containing a range of issues that had been reviewed and investigated
during the month. Items of note included;
Page 5 of 8
Action
UNCONFIRMED
Item 14.45
Ref.
Enc 01
Item
There were no serious untoward incidents in January 2014 and no Never Events since
last April. An analysis of SIRIs showed no evidence that they occurred in particular
ethnic groups or at specific times of the day or days of the week
The crude number of deaths per 1000 patients, PICU and cardiac and liver transplant
mortality run charts, plus reviews of individual deaths showed no evidence of
systematic care failing . However, the trust's Hospital Standardised Mortality Ratio
(HSMR) remained high. This had been looked at internally and it was felt that the
current ratio calculation was not appropriately risk adjusted as it was predominately
adult based and did not reflect paediatric diseases. VD said that the safety team were
considering how to develop a more appropriate measure with the other children's
hospitals, and how to introduce external review into the mortality process. SJM also
asked whether deaths could be graded on 1-4 scale of preventability as had been done
in the two previous mortality annual reports? VD said this would be done, but there
would be a delay between the death and the report since the grading was done after
speciality review and the trustwide mortality group. The current board report
containing individual details of every death only relates an initial review by a senior
nurse and senior doctor.
In the updated list of current inquests, the background to item 4 was explained, based
on a delay in administering antibiotics to a septic child on intensive care. The trust's
own investigation had focused on systems but the trust solicitors had commissioned an
expert opinion which focused more on the actions of individuals. This was being dealt
with.
MM reported.
The patient feedback App was now attracting media interest.
Safeguarding level 2 training was not good enough; the need to increase the figure was
being reviewed, possibly by on-line training.
The Safe Kids Audit tool was being looked at by Salford who were impressed with its
function.
The Board noted the report.
14.38
Performance Report
DM presented the report, which had earlier been reviewed by the Finance & Resources
Committee. The following key issues were highlighted and discussed;
Diagnostic waiting list – MRI
The original forecast which predicted the back-log of existing operations would be cleared by
May now, due to a spike in February, suggested the trajectory would not be cleared until June.
It was clear that the Trust didn’t have the capacity to manage unexpected increases in demand.
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Action
UNCONFIRMED
Item 14.45
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Item
The service would benefit from the return, after maternity of a radiologist. In addition a range
of measures were being examined to try and improve the position, including Saturday and
Sunday working.
Cancelled Operations
In January 15 patients had their operation cancelled on the day due to hospital reasons. This
was lower than previous months and the current average. However there were a further 39
patients who had their operation cancelled the day before and 4 patients who breached the 29
day standard in January.
It was noted that the PWC report on this matter would be presented to the F&R Committee in
March.
Emergency Department
Continues to perform well, meeting the 4 hour target in January.
18 Weeks
The standard was met in January with performance at 90.3% against the 90% standard.
The Board noted the report.
14.39
Resources Report
A strong performance in January had led to the Trust being £2,113k above target.
The forecast year end surplus of £8m was inflated by the unexpected receipt in the last two
weeks of £2.1m for the CAHM’s service. This was unexpected, but presented a problem on how
to explain the receipt at the year end.
CIP performance had deteriorated against plan and now stood at 28% below planned schemes.
The Trust had benefitted from a strong cash balance with reduced capital spend due to delays
in the electrical infrastructure work and the cancer centre.
TN reported.
Sickness levels had reduced by 0.2%, dropping below 3.5% for the first time since
September.
The Trust was continuing to engage with staff on the impact of stress to help reduce
the problem.
Staff appraisal rates remained static at 83%, continuing to fall short of the 90% target.
The Board noted the report
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Action
UNCONFIRMED
Item 14.45
Enc 01
Ref.
14.40
Item
Foundation Trust finances
PF introduced a presentation centred on the NHS Quarter 3 Foundation Trust performance.
From this it was clear that the Acute services remained the most challenged, particularly
small/medium sized Trusts, with 18 of the 59 Trusts falling in this category facing financial
difficulties.
As a specialist Trust, BCH remained in line with average financial indicators for this sector.
Specialist Trusts were the best performing sector.
Overall the Midlands remained the most financially challenged area, with 14 of 38 Trusts in
deficit and a further 14 of 37 non Foundation Trusts forecasting a deficit.
The Board noted the presentation
OTHER
14.41
Questions from the Public
There were no questions from members of the public.
Next Board Meeting: 27 March 2014, The Education Centre, BCH
Page 8 of 8
Action
Board of Directors
Public Meeting 27 March 2014
“The Nursing Workforce at Birmingham Children’s Hospital”
Item 14.49
Enc 02
Strategic Objective/ Enabler
Report Title
Sponsoring Director
Author(s)
Previously considered by
Nursing Workforce – The story so far
Michelle McLoughlin
Michelle McLoughlin
Andrew Gralton
Quality Committee (20 March 2014) Finance & Resources Committee (25
March 2014)
Situation
It is essential that we have the right people, with the Right skills in the Right place at the Right time
to enable us to provide the best care we can for the children, young people and their families who
use our services.
Background
The dynamic nature of our services requires us to review and alter our clinical nurse workforce
regularly to ensure we meet the care needs of the children and young people that require our
services. To ensure consistency, changes are based on formal workforce reviews (skill mix)
established within the trust and based on national standards and then daily amendments that
meet immediate need.
There is now a greater scrutiny on how the NHS provides care and a number of recent reports have
been commissioned which reinforce this:
Compassion in Practice (NHS England 2012)
Report of the Mid Staffordshire NHS Public Inquiry (2013)
Review into the quality of care provide by 14 hospitals trusts in England: overview report
Prof Sir Bruce Keogh (NHS England 2013)
A promise to learn, a commitment to act: improving safety of patients in England, (DoH
2013)
The Cavendish review: an independent review into healthcare assistants and support
workers (DoH 2013)
Each has highlighted the importance of having a safe nursing staffing establishment in place.
The NHS Quality Board have recently published: “How to ensure the right people, with the right
skills, are in the right place at the right time”(DoH 2013) which takes the key element from all of
the above reports and identifies a number of expectations regarding nursing staffing which will be
used by our external partners (Care Quality Commission, Monitor, NHS Trust Development
Authority, NHS England) to demonstrate safe and effective care.
The Francis Inquiry and the government’s response has highlighted the need for safe staffing whilst
the National Quality Board report on staffing emphasised the accountability of Board for ensuring
staffing levels are in place.
In a recent roundtable discussion itemised in a HSJ article (Feb 2014) it was noted that the key was to
being able to demonstrate that systems and processes are in place 24/7, 365 days a year and that
ultimately there had to be a focus on professional assurance. The round table discussion identified
that there should be a warning against tick box exercises and whilst staffing may be an indicator of
safety, organisations needed to be mindful not to fixate on them and make the process an industry
out of collecting and measuring data. Further key points were around ensuring rosters were aligned to
demand and pertinent to particular areas and that it is not just about reported numbers but getting
out and seeing how staffing is delivered and very importantly listening to what our staff are telling us.
Assessment
Birmingham Children’s Hospital has an established process of managed nursing workforce
reviews.
These have been based on the foundations of setting the nursing establishments to deliver the
staffing levels at the planning stage. It is essential that robust processes are in place to manage
daily issues and then monitor for compliance and impact upon our nursing workforce and the
quality of care they deliver.
The nursing workforce reviews previously delivered at Birmingham Children’s Hospital meet all of
the expectations currently recommended in the ‘Right People, Right Place, Right Time paper it is:
Evidence based,
Takes into account three key factors, workforce, activity and resources
Produced from the ward team up
Has multi-disciplinary involvement.
Our process at BCH of ensuring safe staffing is based on:-
1. Skill mix foundation: National and International evidence, professional judgement,
validation with activity and available resources.
2. Daily Management: The delivery of safe, compassionate care to children and young people
in hospital is a 24 hours a day, seven days a week challenge. To ensure this is achieved the
nursing management team has developed a robust process for the escalation of any issues
both in and out of hours which ensures that safety is maintained with risk mitigation. We
are currently reviewing this process to identify good practice and formalise current actions.
3. Monitoring:
The review of ward/department use of staffing has been part of our process for some time,
we have an electronic solution to staff rostering and are now working to triangulate this ongoing review with nursing care quality indicators, patient experience and safety data and
would like to further enhance this by an electronic nursing dashboard.
Future Work:As part of our next phase of working we are developing a Nursing Rota policy which will
provide guidance on the expectations of the wards to use the workforce allocated in the
reviews. We are producing a formal Escalation Policy which will build upon the established
work of the Hospital Operations Centre and will formalise the complex decisions that Ward
Mangers, Lead Nurses and the Heads of Nursing make on an on-going basis to ensure that
the wards are safely staffed. We next plan to work with colleagues in the Workforce
Directorate to utilise the forthcoming data from the Staff Friends and Family Test to ensure
that our staffs views are part of this process.
Our current assessment following a workshop attended by the Chief Nurse’s Nursing
Leadership Team is that we are in a strong position to meet and deliver the 10 Expectations
(as identified in “How to ensure the right people, with the right skills, are in the right place
at the right time”(DoH 2013) however we need to explore how we formalise some of our
operational practices so that we capture the complex and dynamic nature of nurse staffing
and that we achieve the requirement of increased reporting detailed within the 10
Expectations. For example, operationally within the trust there is constant monitoring and
management of skills and competencies and patient acuity from a ward to the Directorate
and Hospital Operations Centre. This process engages all level of staff from ward to Head of
Nursing, incorporating patient’s needs, acuity and staffing. While this process is very
successful at meeting the needs of the patients we do not currently record emerging issues,
the actions taken or the outcome achieved.
It is evident that the majority of data required to be presented to the Board and public is
already available within the current reporting systems. The aim of this next phase of work
will be to collate all the current and new data into a single report.
Engagement within the wider workforce within the organisation is being coordinated
within each work-stream and at the most effective time.
There is a pilot in April when all staffing numbers will be visible on the entrance to some wards.
There will be monthly updates to the Board as part of the Workforce report in the Resources report.
The Board will receive 6 monthly updates with the detailed information on nursing workforce.
Recommendations
The Board is asked to note the work already undertaken so far and the schedule for reports to the
board.
Key Risks
Risk Description
Controls
Risk Description:
Controls:
There is requirement to reports
staffing numbers to our
commissioners immediately.
This data needs to be accurate
and understandable. We need
to clearly explain why the data
received from our Trust will be
different that that received
adult providers.
Data produced about nursing
workforce should be validated
before it is presented our
external Partners.
Assurances
Current practice standardised
We currently have no real time
Acuity system
While risk mitigation occurs on an
ongoing basis there is currently
little record of this for example
our need to produce an Escalation
Policy or that there is not a real
time Acuity system policy
Key Impacts
Strategic Objectives
CQC Registration (state
outcome)
NHS Constitution
Every child and young person cared for by Birmingham Children’s
Hospital will be provided with safe, high quality care and a
fantastic patient and family experience.
The CQC is currently developing a new approach to monitoring,
inspecting and rating providers, staffing capacity and capability
will be central to this new approach
Other Compliance (e.g.
NHSLA, Information
Governance, Monitor)
Equality, diversity & human
rights
Trusts Contacts
Others
Monitor will expect that NHS Foundation Trusts have the right
people, in the right place at the Right Time and will act where the
CQC identifies deficiencies in staffing levels
The need to have the Right people, in the Right place at the Right
time must be developed in tandem with the Trust’s Equality and
Inclusion agenda to better match the our workforce with the local
population and our service users
It is clearly defined that commissioners will actively seek
assurance that the right people, are in the right place at the right
time within providers with whom they contract.
The Nursing Workforce at BCH: The
story so far
February 2014
Michelle McLoughlin, Chief Nurse
Andrew Gralton, Head of Nursing Workforce
Context
The Francis Inquiry and the government response to it have highlighted the need for safer staffing. HSJ
February 2014 identified that there can be no hotter topic in the NHS at the moment than getting the
‘right staff in place’.
Five key papers have been produced in the
last 18months setting out a road map to
better care within the NHS
•
•
•
•
•
Compassion in Practice (NHS England 2012)
Report of the Mid Staffordshire NHS Public
Inquiry (2013)
Review into the quality of care provide by 14
hospitals trusts in England: overview report
Prof Sir Bruce Keogh (NHS England 2013)
A promise to learn, a commitment to act:
improving safety of patients in England,
(DoH 2013)
The Cavendish review: an independent
review into healthcare assistants and
support workers (DoH 2013)
‘Right People, Right Place, Right Time – A
Guide to nursing and care staffing capacity
and capability. (NHS England 2013)
Context
•
There is evidence which suggests that there
are better patient outcomes when people, in
the right place at the right time.
•
There is no single ratio or formula that can
calculate the answer to such a complex
question, as how well is this ward staffed?
•
We need to be more open and transparent
to our patients and the public about how
wards are staffed.
•
It is thought that at this time staffing levels
will not be mandated although there is much
debate about this.
Right People, Right Place, Right Time – A Guide to nursing and care staffing capacity
and capability (2013).
The paper contains 10 Expectations which are:1.
Boards take full responsibility for the quality of care provided to patients, and as a key determinant of
quality, take full and collective responsibility for nursing, midwifery and care staffing capacity and
capability.
2. Processes are in place to enable staffing establishments to be met on a shift to shift basis.
3. Evidence –based tools are used to inform nursing, midwifery and care staffing capacity and capability
4. Clinical and managerial leaders foster a culture of professionalism and responsiveness, where staff feel
able to raise concerns.
5. A multi-professional approach is taken when setting nursing, midwifery and care staff establishments
6. Nurses, midwives and care staff have sufficient time to fulfil responsibilities that are additional to their
direct caring duties.
7. Boards receive monthly updates on workforce information, and staffing capacity and capability is
discussed at a public Board meeting at least every 6 months on the basis of a full nursing establishment
review.
8. NHS provides clearly displayed information about nurses and care staff on each ward, clinical setting,
department or service on each shift.
9. Providers of NHS services take an active role in securing staff in line with their workforce requirements.
10. Commissioners actively seek assurance that the right people, with the right skills, are in the right place at
the right time within the providers with whom they contract.
BCH - Our story so far
The key elements to understanding
our nursing workforce
•
•
•
•
Workforce
Foundations
Ongoing
Monitoring
Future State
Planning
Describing Workforce foundations
On going monitoring
Planning for future systems and
processes
Identifying out future aspirations
Our Workforce Foundations;
The Workforce Planning Reviews
•
•
Professional judgement:
Every Lead Nurse, Ward
Manager, HoN
External proposed challenges
& advice
Environmental factors e.g.
Location re pt journey
Layout of the ward (cubicles
visibility)
Uplift for: AL, Sickness, Non
clinical time and Study
(range 26.5-28%)
Maternity Leave
excluded
•
Each workforce review at BCH has been based on the best
evidence available:
We have developed tools when they have not existed –
TMR & TMRG Model.
Triangulated to ensure the outcomes are valid
Output of the
Workforce Reviews
An establishment, that is the number of nurses for each ward was identified, the nurse to patient ratio and a subsequent skill mix
expected per ward was defined. This is known as the staffing Plan .
•
Department
Ward 1
Ward 2
Ward 5
Ward 7
Ward 8
Ward 9
Ward 10
Ward 11
Ward 12
Ward 15
Burns
Emergency Dept
Medical Day Care
Medical HDU
Neonatal Surgical
PAU
PICU
Surgical Day Care
Theatres
Ashfield
Heathlands
Irwin
Trust overview – January 2014
Clinical WTE
est
21.2
33.8
28.7
21.6
39.2
36.8
33.5
34.2
33.4
64.8
24.3
57.8
11.5
18
35.5
33.7
258.2
16.5
157.3
28.5
23.8
26.5
•
Beds Nurse to bed Skill mix %
12
20
15
12
13
19
18
16
16
28
7
N/A
14
6
16
19
28
18
N/A
8
14
12
1.8
1.7
1.6
1.9
3.0
1.9
1.9
2.1
2.0
2.3
3.5
0.8 *
3.0
2.2
1.8
9.2
0.9*
3.6
1.7
2.2
82
85
78
86
87
78
83
87
83
86
88
78
84
94
85
82
90
73
77
66
63
65
Ward level example Ward 8
Day/Shift
**
Early
Late
Night
Mon
6 (5/1)
7 (6/1)
5 (4/1)
Tue
7 (6/1)
7 (6/1)
5 (4/1)
Wed
6(5/1)
7 (6/1)
5 (4/1)
Thurs
6 (5/1)
8 (7/1)
5 (4/1)
Fri
7 (6/1)
7 (6/1)
5 (4/1)
Sat
6 (5/1)
5 (5/0)
4 (4/0)
Sun
5 (5/0)
6(5/1)
5 (4/1)
Total staff (RN/CSW)
** No one day has the same requirement i.e. Thursday
afternoon, ward round day
Monitoring Our Nursing Workforce:
Daily Escalation of Staffing Issues
REVIEW PROCESS
• 24 hour service; staffing issues can occur
at any time.
• In hours escalation from ward nurse in
charge, to Lead Nurse to Head of Nursing;
issues raised at bed meetings by Lead
Nurses for shared resolution
• Out of hours, ward nurse in charge
escalates to clinical coordinator
• Actions taken in/out hours to resolve or
mitigate staff shortfalls
• Actions include moving staff from other
areas, staff rostering reviewed, bank staff
requested, study leave cancelled.
Just looking at the nursing numbers is not
the solution its about assurance of real time
assessments (HSJ Feb 2014)
IN DAY TIMELINE
– 8.30 Surgical bed meeting to review
staffing numbers/acuity/admissions
– 9.30 Hospital bed meeting; Lead
Nurses representing all areas.
Hospital Safety Check covering
Staffing/Acuity/Risk/Flow
– 13.45 Bed meeting as above. Repeat
Hospital Safety Check
– 16.00 Additional bed meeting if
required
– 19.00 Clinical coordinator and On call
Senior Manager review. Hospital
Safety Check
Monitoring Our Nursing workforce: Right
Skills , Right Numbers, Right Place
•
•
•
•
•
•
•
Establishment is a starting point
The right skills at the right time need to be
achieved.
The Rotas policy & procedural guide established
roles, rules and articulated expectations.
The implementation of an electronic rota
system, providing a monitoring system recording
our actions and allows for trend analysis.
Workforce reports are already produced
(resources report).
It is crucial that there is not just one data
source.
Listening to staff is always the key.
Monitoring: Our Every Day Management
of the Nursing Workforce
Current State
•
Each day each ward/department assesses their
workforce:
•
In relation to the:
• Number of patients
• Acuity of patients
• Speciality
•
This is done at ward, Directorate level and
hospital level and involves nurse of all levels
Future State
•
Developing from a practice into a process
solution:
– Establishing a data set
– Recording our actions
Need an IT
– Producing a highlight report
solution
– Reporting via the Dashboards
Planning our Response to the 10 Expectations
•
Working groups have been established to undertake the gap analysis for each of the
Expectations.
•
We have a detailed gap analysis against the 10 Expectations from the Right People , Right
Place, Right Time.
•
Action plans have been prioritised against the gap analysis.
Future priority areas:•
The formalisation of the current daily nursing escalation process – Established
practices to formalise the process.
•
The development of a Ward level Nursing Dashboard so that we can publicly display
our daily nursing numbers at ward level – First trial April 2014.
Future State : Providing Assurance to the
Board
Assurance:
–
A monthly report of compliance with
the staffing plans to enhance current
workforce information in resources
report to the Board.
– A 6 monthly update to the Board
regarding nursing workforce
establishment.
Monthly Board Assurance Framework
Monthly Workforce Resources Report
BOARD ASSURANCE FRAMEWORK JANUARY 2014
Item 14.20
Risk
No.
Enc 02
Current Risk
Score &
movement
Strategic Risk
1.0
Failure to change the culture of the workforce may prevent the Trust from meeting its strategic
ambitions.
4x5=20
3x4=12
2.0
Failure to match our service demands to specialist workforce requirements will reduce capacity and
quality of services and impact on the achievement of our strategic objectives.
4x5=20
3x4=12
3.0
The service experience for the patients we treat and their families is poor impacting on both clinical
outcomes and Trust reputation.
3x5=15
2x4=8
4.0
Failure to have long term plan for the physical estate on Steelhouse Lane will frustrate the ambitions
of the organisation to further develop its reputation and services.
4x5=20
3x5=15
5.0
Inability to provide the physical capacity over the medium term on Steelhouse Lane will mean failure
to deliver demand and generate the resources for a new hospital.
4x5=20
3x4 = 12
6.0
An inability to innovate in the way in which we provide care reduces access to and quality of our
services.
4x5=20
3x4=12
7.0
Unnecessary harm is caused to our patients
4x4=16
3x4=12
8.0
The Trust’s IT infrastructure is inadequate for future business needs.
4x4=16
3x3=9
9.0
Failure to work collaboratively across the city/region.
3x4=12
3x3=9
10.
Failure to capitalise on growth and innovation opportunities
3x4=12
3x3=9
11.
Failure to manage the resources available to the Trust in an effective manner.
4x4=16
3x3=9
12.
Failure to manage timely access to patients who require surgery so the Trust meets its 18 weeks target
4x4=16
3x3=9
Board of Directors
Public Session
27th March 2014
Item:14.51
Report Title
Sponsoring Director
Author(s)
Previously considered by
Enc. 03
Monitor Operational Plan for BCH 2014-2016
Matthew Boazman, Director of Strategy & Planning
Matthew Boazman, Director of Strategy & Planning (Lead Author)
Chief Officer’s
Finance & Resources
Situation
The Trust is required to submit its organisational plans to Monitor on an annual basis as part of the
Annual Planning Review (APR) process. New planning guidance has been recently issued by Monitor
which outlines the changes to the planning cycle for 2014/15 onwards. The attached document covers
the operational planning (2014-2016) requirements set out by Monitor as part of this planning
framework.
Background
The planning framework for 2014/15 has changed significantly from previous years in order to address
some of the gaps identified by Monitor following their review of organisational submissions for
2013/14. Some of the key changes are summarised briefly below:
Increased strategic focus
Requirement for robust engagement across Local Health Economy (LHE)
Requirement to self-assess organisational viability
Supported by long term financial projections and modelling
The requirement to ensure there is a robust engagement process with key local stakeholders is
particularly prominent within the planning framework- this includes ensuring that there is a strong
alignment between provider and commissioner planning assumptions compared to previous years. In
order to develop a robust strategic plan Monitor considers it essential that organisations can
demonstrate the minimum following steps within their planning cycle:
-
Put in place a robust planning process and, in particular, ensure sufficient and appropriate
engagement with the key stakeholders within the Local Health Economy (LHE)
Assess the risks to sustainability of high quality services in conjunction with LHE stakeholders
by drawing on accurate inputs that have been analysed and presented correctly
Assess the options available to address the identified sustainability risks in conjunction with the
LHE stakeholders and make choices on which option(s) are most appropriate
Define a vision for sustainability and develop the key initiatives which underpin this, where
appropriate, in conjunction with LHE stakeholders
Set out a plan for delivery including financial projections which are internally consistent and
based on credible assumptions
Assessment
In order to comply with the planning guidance BCH must submit two separate planning documents
which will cover the key operational and strategic challenges:
A two-year operational plan for 2014-2016
-
Submission by 4th April 2014
Review by Monitor April-May 2014
Assess FT understanding of the challenges it faces
Assess engagement and alignment with key stakeholders
Evaluate the congruence of commissioner and provider activity and revenue assumptions
Assess the level of planned capacity available compared to the predicted demand
Review robustness of Cost Improvement Plans and efficiency programmes
A five-year Strategic and Sustainability Review Plan
-
Submission by 30th June 2014
Review by Monitor July-September 2014
Assess the robustness of the strategic planning process
A review of the FT plans for securing its long term clinical and financial sustainability
An assessment of the strategic options that the FT believes are available to ensure the
sustainability of high quality services for patients
Assess engagement and alignment with key stakeholders
Evaluate the congruence of commissioner and provider activity and revenue assumptions over
the five year period
Completed gap analysis against the best practice self-assessment framework
The FT Board is required to complete a self-assessment of its longer term sustainability
(Declaration of Sustainability) and outline the key points to support its conclusions
Recommendations
The attached document is the two year operational plan covering the period 2014-2016. The content
included is aligned to the planning guidance set out by Monitor and covers the specific sections
Monitor expects to be detailed within the submission.
As part of the submission process the Board of Directors is required to review and support the plan
and the final version must be formally signed off by the Chair, CEO and CFO for submission on 4 th
April 2014.
Key Impacts
Strategic Objectives
NHS Constitution
Other Compliance (e.g.
NHSLA, Information
Governance, Monitor)
Equality, diversity & human
rights
The operational plan links with all of the strategic objectives
None
The operational plan is a core component of the Monitor annual
planning and compliance requirements
None
Operational Plan Document for 2014-16
Birmingham Children’s Hospital NHS Foundation Trust
DRAFT : VERSION 7
1
Operational Plan Guidance – Annual Plan Review 2014-15
The cover sheet and following pages constitute operational plan submission which forms part of Monitor’s
2014/15 Annual Plan Review
The operational plan commentary must cover the two year period for 2014/15 and 2015/16. Guidance and
detailed requirements on the completion of this section of the template are outlined in section 4 of the APR
guidance.
Timescales for the two-stage APR process are set out below. These timescales are aligned to those of
NHS England and the NHS Trust Development Authority which will enable strategic and operational plans
to be aligned within each unit of planning before they are submitted.
Monitor expects that a good two year operational plan commentary should cover (but not necessarily be
limited to) the following areas, in separate sections:
1. Executive summary
2. Operational plan
a. The short term challenge
b. Quality plans
c. Operational requirements and capacity
d. Productivity, efficiency and CIPs
e. Financial plan
3. Appendices (including commercial or other confidential matters)
Please note that this guidance is not prescriptive and foundation trusts should make their own judgement
about the content of each section.
The expected delivery timetable is as follows:
Expected that contracts signed by this date
28 February 2014
Submission of operational plans to Monitor
4 April 2014
Monitor review of operational plans
April- May 2014
Operational plan feedback date
May 2014
Submission of strategic plans to Monitor
30 June 2014
(Years one and two of the five year financial plan will be fixed per the final
plan submitted on 4 April 2014)
Monitor review of strategic plans
July-September 2014
Strategic plan feedback date
October 2014
2
Operational Plan for y/e March 2015 and 2016
This document completed by (and Monitor queries to be directed to):
Name
Matthew Boazman
Job Title
Director of Strategy and Planning
e-mail address
Matthew.boazman@bch.nhs.uk
Tel. no. for
contact
0121 333 8533
Date
04/04/2014
Approved on behalf of the Board of Directors by:
Name
(Chair)
Keith Lester
Signature
Approved on behalf of the Board of Directors by:
Name
(Chief Executive)
Sarah-Jane Marsh
Signature
Approved on behalf of the Board of Directors by:
Name
(Finance Director)
David Melbourne
Signature
3
1. Executive Summary
Birmingham Children‟s Hospital NHS Foundation Trust provides children‟s health services for young
patients from Birmingham, the West Midlands and beyond, with over 240,000 patient visits every year.
We are one of the UK‟s four standalone children‟s hospitals, one of 33 providers of specialised
children‟s services, and one of the UK‟s 246 trusts providing hospital paediatric services to the local
population. We provide 11+ national services, 30+ services to children and young people in the West
Midlands, and general and emergency services to the south and central population of Birmingham.
We are characterised by a unique co-location of all the services, specialist expertise and diagnostic
and treatment resources that a sick child needs. The population is characterised by diseases which
have one or more of the following features: rarity, complexity, co-morbidity, unresponsiveness to
conventional therapy, age or acuity.
Our hospital is home to:
 54 specialties
 11 Nationally Commissioned Services
 150,000 outpatient visits a year
 50,000 Emergency Department patients a year
 44,000 inpatient admissions each year
 244,000 patient visits per year
 360 beds across 16 wards at Steelhouse Lane and 4 Child and Adolescent Mental Health
Services (CAMHS) wards at Parkview in Moseley
 14 theatres
 61 parent and family accommodation rooms – the largest facility in Europe
 KIDS regional emergency transport service
 Wellcome Clinical Research Facility
 31 bedded PICU
 £239m annual income
 3,500 staff
The issues we are facing with increasing high demand for our services means we have to continue to
grow our capacity at a rapid pace, not just by building new facilities, but also by organising ourselves
differently to improve our patient pathways. We need to redesign our workforce to use our skilled
professionals in new ways and invest in technology to enable change. If we look ahead to the next
five years, our local population is expected to grow significantly, and we will see thousands more
children every year, with even more complex conditions. Our analysis tells us our current 150 year old
hospital will simply not be able to cope with this demand, so we have been developing options for a
new hospital, either at our current Steelhouse lane site or at Edgbaston within the City.
The development of Birmingham‟s first purpose-built children‟s hospital is an exciting and important
step in our future strategy, but we fully recognise that 2022, the very earliest it could be built by, is too
long to wait, and it is essential that we invest in our future now, to be able to cope with our current
demand projections. For that reason, we are launching our Next Generation project in April 2014 and
this will form a key element of both our operational and strategic plan for the next ten years up until
2024.
4
2. Our Vision
The Trust‟s strategy is based on our mission, which is “to provide outstanding care and treatment to all
children and young people who choose and need to use our services, and to share and spread new
knowledge and practice, so we are always at the forefront of what is possible.”
This is supported by a clear set of strategic goals and our vision of being the leading provider of
healthcare to children and young people in the UK, whatever their condition and wherever they need
our expertise.
Our Mission
To provide outstanding care and treatment to all children and young people who choose
and need to use our services, and to share and spread new knowledge and practice, so
we are always at the forefront of what is possible.
Our Vision
To be the leading provider of healthcare to children and young people in the UK,
whatever their condition and wherever they need our expertise
Our Strategic Goals
Figure 1 The Trust Vision for 2014-2016
3. The Trust Priorities 2014-2016
As part of the business planning process in 2013 the Trust agreed a set of three year operational
priorities covering the period 2013-2016. These have been reviewed at the end of year one to take into
account progress to date and to reflect any key changes to our priority areas and the refreshed
priorities for 2014-2016 are outlined in figure 2.
5
Figure 2 Our Priorities for 2014-2016
We will strengthen Birmingham Children’s
Hospital’s position as a provider of
Specialised and Highly Specialised services,
so that we become the leading provider of
healthcare in the UK
•To develop and promote our strategy for rare
diseases
•To be more ambitious in our delivery of
specialised mental health services, ensuring
children and young people receive the best care
in the best environment
Every child and young person requiring
access to care at Birmingham Children’s
Hospital will be admitted in a timely way,
with no unnecessary waiting along their
pathway
•To ensure that no child or young person has their
appointment or operation cancelled, unless there
is unforeseen urgent clinical priority.
•To provide high quality consistent emergency
medical and surgical care by improving the
patient journey and removing all unnecessary
delays.
Every member of staff working at
Birmingham Children’s Hospital will be a
champion for children and young people.
We will continue to develop Birmingham
Children’s Hospital as a provider of
outstanding local services: ‘a hospital
without walls’, working in close partnership
with other organisations
•To further develop our position as an advocate
and provider of public health advice, improve the
lives of our patients, and all children and young
people across Birmingham
•To further strengthen the voice of children and
young people in how our services are run and
how we promote healthy lifestyles
•To improve the quality of end of life care
•To improve the life chances for young people
with a learning disability by developing a range of
employment opportunities
•To continue to develop, with our partners, a
Birmingham Children’s Network, that enables
high quality, high value health care for children
and young people across Birmingham
•To work with primary care partners to examine
how we might come together to best provide first
line care for children and young people
•To examine, with partners, how we best provide
community mental health services for children
and young people, given the budget reductions
expected from commissioners
Every child and young person cared for by
Birmingham Children’s Hospital will be
provided with safe, high quality care and a
fantastic patient experience
Every member of staff working at
Birmingham Children’s Hospital will be
looking for, and delivering better ways of
providing care, at better value
•To further develop our approaches to gaining
feedback from staff, children, young people and
families to ensure that their voice is heard at
every level of the organisation
•To further innovate our systems to promote and
enhance patient safety and reduce avoidable
harm.
•To introduce technology to improve the service
safety, quality and experience
•To build an organisation of high performing
teams, focussing on quality
6
•To review whether we have the right people,
with the right skills, undertaking key roles to
ensure we can provide high quality services
within the resources available
•To support and develop innovation in the delivery
of care by redesigning a range of of clinical
pathways
•To explore how we can work with partners, to
improve our commercial offer in order to further
support our NHS services
4. Operational Plan
4.1. Our Short-Term Strategic Analysis- Summary
Over the past year the Trust has undertaken a detailed strategic analysis to support the development of
our organisational strategy which has considered:








The specialist nature of the hospital and responding to the increasing centralisation of complex
services into a few national centres as part of the emerging NHS England strategy.
Developing the local Birmingham and West Midlands acute paediatric service offer, working
closely with other local paediatric providers such as Heart of England NHS Foundation Trust and
Sandwell & West Birmingham Hospitals NHS Trust in partnership with the local commissioners
to identify how local paediatric services are best delivered.
Extending clinical networks into the community and secondary care across the West Midlands.
Providing a complete service for children and young people with mental health problems from
specialist community to complex inpatient care.
Developing and promoting our strategy for research and rare diseases in line with the UK
National Strategy.
Improving the quality of our end of life care.
Championing the health and well-being of children and young people in Birmingham, across the
West Midlands and nationally.
The need to address capacity issues in our estate in both the short and long term
Some of the key challenges that we are facing and that have influenced the development of our strategy
in both the short and medium term are briefly outlined in figure 3. These will be explored in greater
detail within the strategic plan that will be submitted to Monitor in June 2014. Within the context of this
operational planning document the specific elements that are driving our short-term capacity model and
the associated operational challenges will be considered in greater detail.
Demographics
Clinical
Evolution and
Technology
National
Designations
BCH
Patient and
Family
Expectations
Policy and
Finance
The changing
face of
secondary
care
Workforce
Figure 3 Key Strategic Issues for BCH
7
Patient & family expectations: - for children and young people coming into hospital can be a
frightening and disorientating experience. Currently much of the hospital is based on old-fashioned
Nightingale wards that offer poor privacy and space for our patients. Upgrading to more single rooms will
offer greater dignity and privacy and also allow parents to sleep next to their children.
Workforce: - healthcare is primarily a service-based industry, delivered by people. The Trust‟s aim is to
attract and retain the best and brightest people in what is becoming an increasingly competitive labour
market. The number of available senior doctors and nurses is gradually decreasing and we will be
competing for a diminishing pool of healthcare workers with other children‟s health care providers both
within the UK and internationally. This is explored in more detail in the people strategy.
Clinical service evolution and technology: - our current estate, due to ad-hoc expansion, does not
provide ideal clinical adjacencies, leading to inefficiencies for staff. In addition the core of the estate is
based on Victorian buildings and does not have the capacity to accommodate large-scale cutting edge
technology such as inter-operative MRI. Many of the Trust‟s national and international competitors are
investing heavily in new infrastructure (Manchester, Liverpool, Sheffield and Great Ormond Street) and
in order to achieve our service ambitions BCH will need to respond.
4.2. Understanding our Demand
In order to develop the operational plan for 2014-2016 it is important that we fully understand our future
demand and capacity requirements. As part of our operational planning we have therefore modelled
through the expected demand for the next two years based on a range of indicators that are outlined in
figure 4 below. These will all have an impact on the future capacity requirements across BCH, both in
terms of workforce and estate, and have helped to form the basis of both our longer term strategic
modelling and our two year operational plan modelling. The factors that will have an influence between
2014-2016 will be explored further within this operational planning document, whilst the longer term
factors will be covered further in the strategic planning document.
Figure 4 Factors Influencing Future Service Demand
8
4.2.1. Demographic & Population Changes
The birth rate in the West Midlands is currently rising, and combined with the effect of migration, urban
centres including Birmingham are experiencing very rapid rises in the number of children and young
people living within them. This has a direct impact on the number of children and young people requiring
treatment, and using our services.
Birmingham Children‟s Hospital serves a local, regional and national population, and has developed an
adapted demographic trend model, that adjusts for local authority specific population projections derived
from ONS data. This enables BCH to recognise the differential impact of local population changes on
secondary care services, and national changes on the specialist paediatric care market. It gives both a
short and long term forecast on likely activity change, which then underpins forecasting in relation to
other factors influencing place and volume of care within services for children and young people.
BCH‟s active model is based on 2013 data, with forward projections to 2021 by year, and a long term
forecast to 2030. It shows a 7.1% increase in total hospital activity by 2021 from 2013 baseline, rising to
a total increase of 8.5% by 2025. The most significant rise in volume is in the 0-4 age group, although
the largest proportional rise is in 5-9 year olds. The model also predicts a shift in length of stay, with
increasing number of admissions in ages that historically have shorter lengths of stay. Based on
demographic change, we expect to see a 4.7% rise in demand for bed days due to the majority of
growth in ages with slightly shorter average lengths of stay.
Figure 5 Demographic Changes for West Midlands 2013-2030 (ONS Data)
Outside of London, the West Midlands is also the most ethnically diverse region in England and Wales.
The ethnic diversity of the population has a significant impact on activity profiles due to rises in case-mix
complexity and birth rates, leading to an increase in demand and rising complications from
consanguineous relationships. Understanding the age profile and demographic of the West Midlands
population and the expected shifts over the next few years is critical for ensuring that we are able to
accurately model expected demand by service area. All of our services have a relatively unique age
profile, in terms of peak activity levels and linking this to the known population changes enables us to
predict more accurately the demand and variation at a specialty level rather than population based level.
9
An example of the methodology that has been used is outlined in figures 6 and 7 below, which illustrates
the significant impact that this can have at a specialty level and point of delivery (theatres, outpatients,
inpatient beds) for BCH. This has informed our operational planning and specialty level activity
modelling for 2014-2016 and beyond.
Figure 6 Admission Profile by Specialty 2012-2021
Figure 7 Bed Day Requirement 2012-2021
Overall we see that demographic change alone will increase activity by an additional 1,500 bed days by
2015, with the largest growth in paediatrics, paediatric surgery and clinical haematology and
blood/marrow transplantation.
As part of the original Strategic Outline Case, developed initially in 2012, we also combined the
demographic changes with intelligence gathered from our clinical leads regarding service changes,
clinical practice and emerging trends. This generated the high level activity modelling for 2020, outlined
in figure 8 below, and we are due to revisit this as part of phase 1 of the Next Generation project.
10
Figure 8 Predicted Activity Levels 2010-2020 (BCH Strategy Unit Modelling)
4.2.2. Market Assessment
In addition to understanding demographic changes it is important to also consider changes linked to
market share and competition from other providers. A full market analysis of key competitors for
Birmingham Children‟s Hospital has been undertaken as part of the strategic planning process and will
be outlined in detail within the June submission as per the guidance. It is important to also consider
whether or not there are likely to be any major market shifts within the lifetime of this operational
planning document- 2014 to 2016. We have evaluated whether there is likely to be any key changes to
the paediatric market within the next two years based on our strategic assessment and this is briefly
summarised below for both the secondary care and specialised services market.
The Market for Secondary Paediatric Care- It is possible to evaluate the current strength of BCH in
the secondary care market by analysing market share data. Over the last few years BCH has continued
to increase its overall market share within the West Midlands region for the provision of paediatric care
(figure 9). The data set covers all locally commissioned activity for 0-18 year olds- it is not possible to
evaluate share for the 0-16 age group although it is clear BCH would occupy a higher market share
percentage in as their presence is diluted by the inclusion of patients aged 16-18 in this analysis.
The increased share illustrates the relatively low risk from other competitors within the secondary care
paediatric market. This, coupled with our intelligence developed through the Children‟s Health Network,
local commissioners and the Royal College of Paediatrics supports the view that secondary care
provision of paediatrics is reducing amongst some providers, with activity shifting to specialist centres,
such as BCH, potentially as a result of the difficulty of maintaining expertise and clinically viable rotas.
Figure 9 Percentage Change in Provider Activity 2006-2011 (HED Data)
11
Specialised Services & The Emerging NHS England Strategy- In terms of the regional specialised
services market BCH is effectively the monopoly provider for the majority of commissioned services with
no other immediate regional competitor. Competition for the specialist paediatric market is therefore
primarily at a national level and continues to be influenced by service designations and direct
competition with specialist nationalist providers. BCH remains in a strong position with regard to the
number of nationally commissioned services provided (figure 10) and there is no indication that market
share will decrease over the period 2014-2016.
19
Number of Nationally Commissioned Services
12
11
9
9
9
7
7
6
5
Figure 10 Number of Nationally Commissioned Services (Adult and Paediatric)
BCH is well placed in terms of the maximising the potential opportunities that may arise from the
emerging NHS England strategy for specialised services. The strategy proposes that specialised
services are provided in centres of excellence and that the number of nationally commissioned providers
reduces significantly from the current number. This aligns well with the strategy that we have developed
and the expansion of our estate, as part of the Next Generation project, gives us the flexibility to expand
our market share as a result as the model is implemented.
Figure 11: Developing Model for Specialist Service Provision
12
4.2.3. National & Local Commissioning Priorities
It is critical that our plans are congruent with both national and local commissioning priorities and seek to
address some of the challenges that will be faced across our Local Health Economy (LHE) during the
next two years. Having an affordable and realistic financial offer from local, regional and national
commissioning bodies continues to be important for maintaining and growing market share. Within our
LHE we have engaged through the local Joint Clinical Commissioning Group and have presented both
the long term strategic challenges and shorter term activity projections to our commissioning partners to
ensure that they are supportive of our operational planning assumptions.
The commissioning architecture of the NHS has changed significantly during 2013 as a result of
changing national policy. As we are now coming towards the end of the first year under this new
architecture the impact and risks identified last year have been reviewed and updated based on
experience during the year. These are outlined below.
-
National service specifications
Provider led networks
Funding for high cost drugs and devices and new treatments
Impact
Risk/Opportunity
Mitigation/Action
National service specifications are now in
place for all prescribed services, where
previously there have been none.
Compliance exercise
highlighted a small number
of specifications where the
Trust was non-compliant;
there is a risk that there will
need to be significant
investment if specifications
are not changed.
Actions identified for all
specifications where there are gaps
There are approximately 60 service
specifications that are applicable to the
Trust.
Opportunity to increase
market share for services
that are able to
demonstrate full
compliance
Move to provider led networks for some
specialised services.
As a specialist trust this will mean that BCH
will be acting as the lead for the network
and so commissioning services from other
providers e.g. Cystic Fibrosis where a
shared arrangement with BCH as the host
st
has been in place from 1 April 2013.
Trust is accountable for the
performance of all
members of the network
and if standards are not
met the Trust would be
responsible for
improvement.
Consolidates position as
specialist provider.
Increases the opportunity to
improve standards and
care across network and
drive innovation.
13
Issues have been raised directly
with commissioners and through
clinicians that sit on the Clinical
Reference Groups.
Derogations currently in place but
not yet received clear feedback on
the future impact, the issues raised
are not unique to BCH.
For Cystic Fibrosis work stream an
internal project group has been
established which considers:
 Contracts and finance
 Quality standards
In addition a wider stakeholder
group is in place which will look at
the development of the network.
BCH is heavily engaged in a range
of national networks and is also
leading on the development of
regional network models for surgery
High cost drugs, devices and innovative
treatments not on the approved list which
previously would have been funded
through Individual Funding Requests (IFR)
Delays in treatment or
treatment not authorized.
Financial risk if drugs are
authorized for use and
funding not secured.
Internal process strengthened to
identify new drugs and treatments
as well as process for individual
funding requests.
Internal group established for BCH
staff who are members of Clinical
Reference Groups
Figure 12 Commissioning Changes & Implications 2014/15
Under the new commissioning arrangements approximately 75% of services are now prescribed
services and commissioned directly by NHS England. The local area team have highlighted that there is
a deficit predicted across their portfolio for 2014/15. Contract negotiations for 2014/15 are based on
forecast outturn for 2013/14 with no growth included. Given the demographics for the region there is an
expectation that there will continue to an increase in demand, this is acknowledged by commissioners
but not within contract baselines. There is limited opportunity for new developments except where these
can deliver QIPP.
4.2.4. Service Reviews and Reconfigurations
In addition to the changing commissioning architecture across the NHS outlined above there are also a
range of commissioner led initiatives that have also been considered as part of our operational planning.
-
Review of paediatric critical care
QIPP and demand management initiatives
Decommissioning proposals
Any Qualified Provider tenders
Impact
Risk/Opportunity
Mitigation/Action
Opportunity to improve capacity
across the region and therefore
improve flow within BCH
BCH are fully engaged in the
review.
Provides stability in 2014/15 but
does not provide any support in
reducing demand on services.
BCH has identified a small
number of areas where QIPP
could be achieved for
commissioners. We will continue
to share ideas where possible.
Critical care review
NHS England commissioners are to
carry out a review of critical care
provision across the region - will
include intensive care and high
dependency care provision
QIPP and demand management
Commissioners have not identified
any areas where they plan to
implement demand management
plans or to apply QIPP as part of the
2014/15 contract.
14
Decommissioning
Commissioners have indicated that
they will be decommissioning the
current community CAMHS. This will
be subject to competitive tendering in
2014/15 with the new contract going
live from October 2015.
Impact on morale of the
workforce and risk of staff
leaving.
.
Financial risk associated with
tender process for BCH.
Inability to redesign service for
18 months.
Regular communication with staff
is in place to keep them informed.
Management team within the
service is working to continue to
make improvements where
appropriate.
Current outcome measures are
positive and will continue to be
monitored.
Any Qualified Provider
Limited impact for the Trust.
A 0-25 year old mental health service
is being tendered for Birmingham
which will include the current CAMHS.
Loss of contract, new provider
operating in Birmingham for
CAMHS.
Delivery of the new service would
mean a partnership with another
provider so that the full range
could be delivered. This is being
explored.
Significant resource will be
needed to deliver the bid.
Loss of the contract for
community services may impact
on our ability to continue to
provide Tier 4 services.
National congenital heart review.
Launched a year ago following the
end of Safe & Sustainable review.
Examines the organisation of
children‟s and adults congenital heart
services across England.
Further development of BCH as
a larger specialist centre.
The timetable for implementation
of the new standards led
approach is at the earliest during
the 2015/16 financial year.
Trust has representation on both
the clinical group management
group supporting this change.
Assumed no impact other than
natural demand increases in our
modelling.
Figure 13 Service Reviews 2014/15 and Impact Assessment
4.2.5. Children and Adolescent Mental Health Services (CAMHs)
During the planning period covered by this plan commissioners are undertaking a market testing
exercise on our community CAMHs. The Trust is commissioned to provide these services for children
and young people up to the age of 16. Birmingham & Solihull Mental Health Foundation Trust is
commissioned to provide the services for ages 18 plus. The commissioning strategy is to market test the
whole 0-25 service and they have indicated that the successful bidder will be characterised by a single
lead provider. The tender process is expected to be completed by April 2015 with full transition by
September 2015.
15
The Trust has consistently cross subsidised community CAMHs from other service lines and
commissioners had proposed a further funding reduction of £1.4 million per annum from April 2014. We
have been able to secure transition funding of £2.1million to cover an annual funding gap of £1.4million
over the period until September 2015. We are currently working with other partners in developing our
intent to bid. Our financial plans assume a downside financial scenario – (the specific details of which
are of a commercial nature).
4.2.6. Regional Reconfiguration and the Potential Impact on BCH 2014-2016
As part of our operational planning for 2014-2016 we have considered three potential sector
reconfigurations that may have an impact on BCH during that time frame.
-
Worcester Acute Hospitals
Mid-Staffordshire NHS Trust
The George Eliot Hospital
Worcester Acute Hospital Reconfiguration- one of the major potential service reconfigurations within
our Local Health Economy relates to the reorganisation of Worcester Acute Hospital NHS Trust. The
Future of Acute Hospital Services in Worcestershire Report of the Independent Clinical Review Panel
was published in January 2014. The suggested changes that affect paediatrics are:




Paediatric inpatient beds should be closed at the Alexandra Hospital (AH).
A networked “emergency centre” should be developed at AH. The emergency department at AH
will be adult only. A 24 hour Urgent Care Centre (UCC) and a minor injury unit should be
developed at AH, both of which will treat children.
A paediatric assessment unit (PAU) should be developed at AH and will be open until 10pm.
PAU will accept referrals from the UCC and GPs.
Consultant led maternity services at AH should be moved to Worcester Royal Hospital.
Figure 14 Outline of Proposed Worcester Reconfiguration
The current proposals are going out to public consultation with implementation being completed in
2015/16 at the earliest. It is therefore possible that the proposed model for Worcestershire will not be
16
implemented during the two years covered by this operational plan. However, it is necessary to
consider what the implications might be if the new model was to be implemented, particularly whether it
will lead to an increase in paediatric attendances. Some of the key issues that we have considered are:
•
•
•
The potential increase in A&E attendances
Increase in the number of emergency admissions at BCH, which may increase even further after
10pm when the paediatric assessment unit at AH closes.
Some mothers will choose to go to Birmingham Women‟s rather than Worcester Royal Hospital
for maternity care, potentially linked to easier public transport. Therefore there may be increased
transfers from Birmingham Women‟s Hospital NICU to BCH.
The impact of travel time has been considered in further detail by looking at the main post codes areas
where our activity comes from in terms of paediatric activity across Worcestershire- the two highest
concentrations are unsurprisingly focused around Bromsgrove and Redditch.
Using this data it is possible to review the likely travel time associated with road and public transport as
this was highlighted as one of the key factors within the review document for determining patient, and
parent, behaviour and has also been highlighted by the King‟s Fund as one of the key determinants in
patient behaviour. The data (figure 15) illustrates the potential impact public transport may have on
choice. At this stage we have therefore assumed that there will be some shift in activity that might
come to BCH within the next two years as a result of the WAH reconfiguration.
Figure 15 Travel Times for Bromsgrove & Redditch Residents
Mid-Staffordshire NHS Trust- pending the implementation of the Trust Special Administrators (TSA)
recommendations, paediatric flows through Mid Staffordshire will alter significantly. Historically, Mid
Staffordshire has treated approximately 9,000 Finished Consultant Episodes (FCE) for paediatrics,
largely focussed around short stay admissions. It undertakes around 1000 paediatric surgical
procedures per year, but these are largely non-complex. The trust does not have a paediatric surgery
department. Our flow assessment aligns with the TSA report that the majority of this activity will now be
undertaken through University Hospital North Staffordshire and hospital providers in the Black Country
with minimal impact on demand at BCH. We continue to monitor the outcomes of the review around
consultant led obstetric services on the Stafford site, as this is also likely to impact on future paediatric
service models North of Birmingham.
George Eliot- there is some potential for paediatric services at George Eliot hospital to be reconfigured,
as part of the hospital‟s future model review. The new service model includes a PAU at George Eliot,
with onward referral to University Hospitals Coventry and Warwick (UHCW) Trust. The needs
assessment identified activity of 1676 inpatient admissions, but estimated only 12 per week would
require transfer for inpatient care, for which UHCW is developing additional capacity. Our flow analysis
again suggests that any further changes would have minimal impact on our inpatient and surgical
services. We have identified a geographical sector that would potentially use Birmingham Children‟s
Hospital if no services were to be available at George Eliot, but population density is low in these areas,
and any impact would be shared with UHCW. We do not therefore envisage there being any major
impact as a result during 2014-2016.
17
4.3. Dealing with Demand- operational capacity for 2014-2016
As outlined in section 4.2 above there are a range of factors that will influence, and in the majority of
cases increase, the likely demand on our services between 2014-2016. These will continue to present
us with real challenges in terms of service demand, particularly across some of our more specialised
clinical services, such as PICU and cardiac surgery.
4.3.1. Next Generation Project
The issues we are facing with increasing high demand for our services means we have to continue to
grow our capacity at a rapid pace, not just by building new facilities, but also by organising ourselves
differently to improve our patient pathways. We need to redesign our workforce to use our skilled
professionals in new ways and invest in technology to enable change. For that reason, we are
launching our Next Generation project in April 2014. This project has two phases;
-
Phase 1- today until 2022
Phase 2- our new hospital from 2022 and beyond
Planning for these will overlap, but they are part of the same ambition for children and young people.
Next Generation must not be seen as purely a buildings project as both of these phases are about
more than just bricks and mortar, and have four key components:
1.
2.
3.
4.
Patient pathways – How can we make them the very best they can be?
People – What teams and skills do we need to invest in to make these pathways a reality?
Technology – How can technology act as a catalyst to radical new ways of delivering care?
Facilities – How can our buildings help us to increase capacity, and improve the environment?
Patient Pathways
Better patient pathways improve patient care and help us maximise our capacity
The paths that our patients take to get to us, the way they are looked after while they're here, and how
18
this continues when they've gone home, is what makes their experience of care what it is. We know
that in general, our children, young people and families want to get better and get home as soon as
they can, and we work hard to make that happen.
One of our most recent improvement projects has been to our emergency care pathway. By creating
our Paediatric Assessment Unit, and Hospital at Home team, we have been able to better manage the
flow of patients into hospital beds, allowing us to care for those most in need, more quickly. Building
on this we will now focus on our current „hot spot‟ pathways – outpatients and surgical flows. Working
with frontline staff that struggle on a daily basis to get patients in and treated, we will determine what
improvements can be made to be more efficient, and through this we know we will be able to see
patients more quickly, with fewer delays. This programme of work will form the basis of our EQUIP
work stream (Enabling Quality Improvement).
People
The best teams deliver the best results
Like many hospitals around the country we continue to face staffing challenges due to national
shortages of specialist doctors, nurses and other healthcare professionals. This is why it is more
important than ever to look at how we can work differently and ensure we have the right skills, at the
right level, rather than be fixated on old fashioned workforce models that we could never recruit to
anyway.
Training also plays a critical role in the success of our people, and amongst our ongoing training
programmes, a key area of focus will be equipping managers with the skills and knowledge to support
staff to deliver better services. Our Team Maker Programme is the cornerstone of this.
We also need to be realistic given the fact that we, and the NHS as a whole, face the biggest financial
challenge in our history and as a result it has never been more important to make every penny work
hard for us. Sometimes this is about getting the basics right and we hear about great common sense
ideas all the time that just need to happen. Through a Trust wide campaign we will support people to
make better use of our funding, so we can reinvest more into patient care.
The Trust‟s People Strategy sets out our commitment and plans for developing and supporting every
member of staff to be the best they can be.
Technology
Taking the hassle out of healthcare
Technology will play a critical role in delivering our Next Generation project. We have a clear vision and
strategy for how we will use technology to enhance the quality of care we provide for children and their
families, and at the same time improve our working lives. Our goal is to go paperless, and to do this in
the next few years through Paediatric Electronic Patient Record (PEPR) programme.
PEPR will be a place which will:




Bring together integrated information to support clinicians in running their services- for example
clinic lists, ward lists, operation lists, inpatient lists, activity data
Bring together information to improve decision making and clinical care – for example
demographic details, tests, scans, medicines, correspondence within a single electronic patient
record
Help us communicate better with children and families by providing direct access to information
about care, and let them provide feedback directly to clinicians.
Help us communicate better with other healthcare professionals – general practitioners and
also other professionals who ask our advice, and from whom we ask advice.
19
Facilities
Great buildings support great care
Our hospital is old, cramped and restrictive, and we must look at how our existing buildings can be
remodelled and where new buildings could be built on site, to keep us going through to 2022. Our
Board has committed £35 million to developing our site, on top of the £9 million already allocated to
Parkview. The project team will develop our business case for approval by the end of 2014, with
building work due to be completed by early 2016.
In December 2012 the Board reviewed the initial Strategic Outline Case (SOC) for the development of
a new children‟s hospital facility in Birmingham. This was based on analysis that indicated in order to
meet demand over the medium and longer term and maintain and improve market share new facilities
would be required. In approving the case the Board recognised:


Whilst there were two options that were feasible – develop at the back of the current city centre
site or move to Edgbaston co-located with UHB, with a new joint facility with BWH, the latter
was the favoured option. This would require service reconfiguration and close working between
Birmingham Women‟s Hospital NHS Foundation Trust and University Hospitals Birmingham
NHS Foundation Trust.
Assuming the development of a new hospital in 2022 investment was required over the medium
term to meet demand requirements. Our modelling has indicated that the Trust would require
four new theatres, additional beds and associated patient and carer facilities (e.g. Parent
accommodation).
We have worked with our partners since January 2013 to develop a solution in the City Centre that will
provide a legacy facility if the main hospital site is to move. Up until 2022 this will be mainly utilised by
BCH, post 2022 it will be shared by BCH and UHB providing a specialist facility and addressing some
of the access issues that were raised by commissioners during the development of the SOC. The Trust
has appointed a range of professional advisors to support the development of this legacy solution and
we would expect a business case to be submitted to the Trust board in the autumn of 2014 with a
value of £35million. We would expect a start on site at the end of the period covered by this plan and
capital expenditure associated with the demolition of the multi-storey car park on site on which the new
clinical block will be located.
We are currently exploring the funding options for this new facility – starting with a strong cash position
and £4million collected via fundraising for the children‟s oncology element of the new facility. We would
expect the majority of the capital to come from these internally generated resources but may consider
a loan from the Foundation Trust Funding Facility for a small element. Our June 2014 submission will
include full details of the financing of this facility.
4.3.2. The Better Care Fund
In addition to the Next Generation project we are also actively engaged within our local health
economy with the Better Care Fund (BCF), which presents us with a unique opportunity to strengthen
integrated working across the region. The BCF plan requires local areas to formulate a joint plan for
integrated health and social care and to set out how their single pooled BCF budget will be
implemented to facilitate closer working between health and social care services. Work undertaken
through the development of the BCF plan for Birmingham has resulted in a shared commitment to
develop a viable health and social care system which more appropriately responds to the needs of
individuals who are vulnerable.
The programme focuses upon an aspiration to maximise the opportunities for providing quality care
including mental health in a variety of community based settings, with a focus on preventative and
20
proactive care, only admitting to a hospital bed when it is the right thing to do so. This means avoiding
non-qualified admissions and discharging people from acute care at the optimum time into more
appropriate alternatives.
There is a system wide piece of work to model the implications of this shift using a 7 day maximum
length of stay for an unplanned spell within a typical acute district general hospital setting. This along
with information about the type of services required enables an informed assessment of the type and
volume of community alternatives needed.
We are a member organisation within the Birmingham Integration partnership board and therefore
influential in developing the delivery plans. As an organisation we are supportive of these plans and
they are in line with our own strategy.
5. Key Performance Risks
There are two specific areas that have been highlighted within our operational plan for 2014-2016 in
terms of key operational performance risks and these are outlined below:
5.1. Diagnostic Waits
The Trust has failed to meet the 6 week diagnostic wait target for MRIs since January 2013. There are
a number of factors which have contributed to this.
-
Increased demand for diagnostic imaging
Increased proportion of requests requiring general anaesthetic
Lack of capacity in the workforce
These factors have led to a backlog and the service has been unable to flex to meet spikes in demand
that have been seen during some weeks of the year. A number of actions have been taken and are
planned which aim to bring performance back in line with targets and to ensure that the service is
sustainable. This includes actions to reduce demand as well as increase capacity:
-
Approval for recruitment of additional radiologists and radiographers
Use of mobile scanners
Increase in GA sessions
Improved use of tools for modelling and forecasting demand and capacity
Figure 16 Performance Trajectory Diagnostic Waits
Based on current assumptions it is forecast that the target will be met from June 2014. BCH has
21
commissioned an independent clinically lead review from the transformation team at the Royal College
of Radiologists to assess the actions taken and working practices to identify any further improvements
that can be made.
5.2. Cancelled Operations
The level of cancelled operations, both on the day and the day before, continues to be a concern to the
organisation. The single biggest reason for cancellations continues to be access to a PICU bed.
There are also issues around ward beds and theatre capacity. Significant work has been completed in
2013/14 to address some of the issues this has included reviewing the surgical pathway processes. In
addition an external review was carried out by PWC to consider the actions taken and any further
actions. A number of actions have been taken and are planned in 2014/15:




Increased capacity through use of other facilities plus internal capital works;
Increased anaesthetic capacity;
Transformation programme to include focus on theatre scheduling and booking;
Implementation of pre assessment service;
This will remain a priority for 2014/15 in particular focusing on a reduction in the number of children
who are cancelled more than once and those cancellations which are due to administration errors or
equipment failure.
6. The BCH Clinical and Quality strategy (2014-2016)
One of our strategic objectives is that “Every child and young person cared for by BCH will be provided
with safe, high quality care and a fantastic patient experience.” In order to deliver against this objective
we have developed our clinical and quality strategy which has a key focus on ensuring that we further
innovate our systems to promote and enhance patient safety and reduce avoidable harm.
Some of the key projects and highlights of our quality strategy planned for 2014-2016 are outlined
below:
-
Implement and embed the Safer Clinical Systems Handover Project Trust wide.
Pilot and review the use of the Safety Case approach as a method for embedding quality
review of service delivery across the organisation.
Support the development of the national Paediatric Safety Thermometer building upon the
SCAN work
Re-launch the Sepsis Care Pathway.
Implement SHINE 12 – „Listening to You‟ – a tool to measure parental concerns and
standardise the format for handing over care between a parent and a nurse.
Improving situational awareness by introducing the proven „huddle‟ model to improve
communication and address underlying cultural causes for safety failures.
6.1. Developing the Strategy
As we continue to make technical advances in the clinical care we deliver, so we must advance in our
approach to patient safety. To achieve this we need to shift away from the traditional definition of
safety as being the absence of harm. Instead, we need to consider safety as the ability to succeed
under varying conditions, so that the number of intended and acceptable outcome is as high as
possible. In so doing, we can learn from what goes right with the clinical care we deliver. This
affirmative action will foster greater transparency and an enhanced safety culture within our
organization.
22
The emphasis of our patient safety strategy is therefore focused on people and relationships for 20142016: our engagement and empowerment of children, young persons and carers, the growth and
development of our staff, and design of our clinical systems to support our staff in delivering high
quality care. The following sections will outline the key themes that we will focus on as part of our
patient safety strategy for 2014-2016 and also summarise the key priority areas within each theme.
Theme One: Ensuring that things go right- a proactive approach to safety
We will look at what goes right as well as what goes wrong with the clinical care we deliver. We
will learn from what succeeds as well as what fails, recognising that things go well because
people make sensible adjustments according to the demands of the situation.
-
-
Favourable Event Reporting – We will develop and implement a system of reporting for well
managed events with positive outcomes to mirror and compliment the incident reporting
system. This is to ensure that we are able to learn from what has gone right as well as what
has gone wrong.
We will design a model of a successful investigation based on a review of investigations and
their relative successes in improving outcomes.
When something has gone wrong, we will look for everyday performance adjustments that
people usually make and the reasons for them.
-
-
Through Root Cause Analysis investigations we will look to identify both performance
adjustments which are appropriate and necessary and inform the qualities of a resilient team
but also those performance adjustments which are necessary to mitigate risk inherent in our
systems.
We will look in detail at every monthly Clinical Risk & Quality Assurance Committee at a
minimum of at least one significant risk by applying risk methodologies which not only take
account of past harm and likelihood of harm but consider potential „harm loops‟ prevented by
the performance adjustments and inherent resilience of our staff.
We will look at what happens regularly and focus on events based on how often they happen
and not just how serious they are.
-
We will include a monthly aggregated analysis of Patient Experience Feedback sources to
include, SIRIs, the Patient Experience Feedback database, Complaints and PALS contacts
within the Quality Report to Board.
We will allow clinical teams time to reflect, to learn and to communicate to enable consolidation
of experiences and understanding of situations of clinical care provision.
-
The “Closing the Gap in Patient Safety: Redirecting the clinical gaze to reduce harm and drive
cultural change through better communication in children‟s wards” project aims to introduce the
proven „huddle‟ model to improve communication and address underlying cultural causes for
current safety failures. Specifically, the project aims reduce avoidable error and harm to over
4,000 acutely sick children by 2016, to involve as many parents and patients better in their care
and to evaluate the cultural change, allowing the learning to be applied beyond paediatric
wards.
23
Theme Two: Building workforce capability in quality improvement and patient safety
science
We will deliver training in Quality Improvement and Patient Safety Science for our workforce.
-
We will build a patient safety and quality improvement faculty and develop a Foundation in
Improvement Science module including the following elements:
o Mapping, Measures, Modify, Model, Maintain
We will coach clinical frontline teams to enable them to implement patient safety and quality
improvement initiatives.
We will implement a Coaching Scheme that will seek to:
-
Identify existing resources and develop an informed coaching support network
Develop a mechanism for access to the coaching support network in relation to patient safety
and quality improvement initiatives
Build on existing resources to widen and strengthen the network
We will continue to develop the UK “Making it Safer Together” (MiST) Group with our peers,
sharing outcomes and data with the group.
Theme Three: Design Human Factors into our clinical systems
We will use Human Factors Science to make our clinical systems safer for patients, more
reliable and resilient and to improve the well-being of our workforce.
-
Patient Safety is one of the foundations of EQuIP. The Programme will ensure, through the
clinical forum that Human Factors Science is included within all service redesign projects.
Theme Four: Continual Learning – better use of patient safety and quality information
We will re-balance our safety measures to enable us to ensure care will be safe in the future.
-
We will work with our paediatric partners to develop a true paediatric risk adjusted Standardised
Mortality Ratio which could be used internationally.
We will measure whether we are responding and improving from our understanding of our
safety information.
-
We will conduct an annual safety culture survey and use this to inform priorities for pro-active
risk reduction.
Theme Five: Transparency of our quality and patient safety information
We will use safety cases to explicitly state the safety and vulnerability of our clinical systems.
-
We will use safety case methodology to assess the safety of surgical pathways and challenge
and test the effectiveness of our risk controls.
We will actively engage in sharing of our patient safety data with our staff, users of our
services, other NHS organisations and the wider public.
-
We will circulate the Monthly Quality Report to all staff
We will provide summaries for front-line staff which disseminates learning from SIRI
Investigations
24
-
We will provide dedicated Patent Safety Intranet resources for staff
We will develop the shared reporting and interrogation of risk data for wider staff groups via the
Vesper reporting platform
We will actively engage patients and carers in quality improvement and re-design of our clinical
systems.
-
The Young Persons Advisory Group will provide a patient forum to approve and monitor the
progress of EQuIP projects.
7. Quality & Safety Governance
Birmingham Children‟s Hospital is continually striving to improve the quality of the services it provides,
in terms of safety, patient experience and clinical effectiveness. Quality continues to be at the heart of
our strategic objectives which ensures a constant focus on quality at all levels of the Trust, including
meetings of the Board and its committees. The committee structure is designed to support the Board to
focus on the right things.
7.1. Quality Report
A monthly Quality Report is produced and reviewed at the Trust Board, Quality Committee, Clinical
Risk & Quality Committee and the Senior Leadership Team meetings. The report includes information
on serious incidents, complaints, mortality data, cardiac arrest, respiratory arrest, other acute life
threatening events, infection control data, safety thermometer and range of patient experience
indicators.
Information on Never Events and other safety information is reported by exception, including the
progress of key projects related to the Safety Strategy such as the Safer Clinical Handover Project and
the Sepsis Care Pathway. The report contains detailed monthly updates looking at mortality data, a
summary of which is provided below, and is supplemented by a mortality case review. The case
review includes a summary of all deaths in the previous month and whether or not any potential care
management issues have been identified.
7.2. Mortality data
In addition to the review of individual deaths, mortality data is presented to both the Quality Committee
and The Trust Board using a range of performance indicators in order to provide the appropriate level
of interrogation and assurance. Indicators reviewed include:
•
Absolute number of deaths per time period.
•
Number of deaths per time period per 1000 admissions.
•
Standardised mortality ratio
•
Cumulative sum (CUSUM) charts
7.3. Internal Assurance and the Board Assurance Framework
The Board Assurance Framework (BAF) provides a structure and process to enable the Board to
understand and focus on the risks to achieving the organisation‟s strategic objectives and to assist the
Board in discharging its responsibility for internal control. The BAF is presented to the Board for review
at each monthly Board meeting. The content of and process surrounding the BAF were reviewed by
the Internal Auditor in 2012/13. The review gave significant assurance, but a number of
25
recommendations were made for improvement, and these have been implemented. This included a
Board workshop to reassess the Trust‟s risks, which took place in February 2013. The outcome of this
workshop has led to further development of the BAF and a review of the goals we must achieve to
meet our strategic objectives.
A further review is being undertaken for the 2014/15 period, the current high level BAF is presented
below (figure 17) and shows the assessed level of strategic risks up to the February 2014 Trust Board.
Figure 17 Summary Board Assurance Framework
8. The BCH Participation & Patient Experience Strategy (2014-2016)
We want our patients and families to feel that they will be cared for, will feel safe and will feel confident
in their treatment. In making this a reality for all of our children, young people and families it is
essential that we work in partnership to ensure their opinions are heard, feedback is acted on and
lessons are learned. The Participation & Patient experience Strategy will ensure that we engage and
involve children, young people and families in the planning, provision and evaluation of all aspects of
our services as outlined in section 242 of the NHS Act.
In order to ensure children and young people are placed at the forefront of the care they receive and
are key stakeholders in influencing the quality and delivery of their health service we maintain a „toolkit‟
approach and currently gather a wide range of information from different sources including, including
feedback cards, e mail, ward walkabouts, verbal feedback; all collated on the Patient experience
Database (PED), the Friends and family Questionnaire, Patient Opinion and more qualitative feedback
from patient experience and participation projects such as patient stories, quality walkabouts, patient
shadowing and mystery shopper experience.
In the last year we have moved to a more real time data collection and responsiveness. This has been
enhanced by a new communications tool – the feedback app- and is also increasingly being supported
by the use of social media including Facebook and Twitter. The feedback app has provided an
opportunity for parents, children and young people to let us know about their experience, both positive
and negative, in real time and has enabled staff to respond directly in real time too.
26
The objectives that have been developed as part of the Participation and Patient Experience Strategy
for 2014-16 are outlined in figure 18 below.
Objective
Measure
Secondary Measure
Build on existing work to
further develop robust
systems and processes for
gaining both qualitative and
quantitative feedback from
CYP and families.
-
CQUIN target for 2014/15 met
Volunteers will begin to
undertake regular surveys
Continue with Tea @3 initiative
and evaluate
Switch over to Vesper reporting
services for both PED and
Friends & Family
Pilot drop in sessions on wards incorporate child & family
information
Enhanced use of social media
-
Quarterly trend analysis
available triangulating
PALS/complaints & PE data
-
-
-
Develop more robust analysis
and triangulation of
complaints and PALS with PE
to inform improvement
-
-
-
-
-
-
To lead a Trust-wide
'campaign' style approach to
make improvements in
identified themes or services
-
The Trust Board will play an
active leadership role in
advocating improvements in
the patient experience
-
Develop a minimum data set
and dashboard for teams and
departments to drive
improvements
-
-
-
CQUIN target for 2015/16 met
Develop a library of short films
of patient experience
Adapt friend and Family in line
with anticipated National
Paediatric roll out in march 2015
Undertake paediatric survey –
currently under review between
Picker Institute and NHS England
Recruit and train young
inspectors to undertake You’re
welcome assessments
Standardised process in place for
measuring satisfaction of
complaint handling and outcome
Annual directorate plans are
developed to address identified
common themes
Evidence of recommendations
from Clwyd and NHSLA
Areas for improvement will have
been identified
Training and education needs
will have been identified
-
Annual Trust strategic objective
will be influenced by patient
feedback
‘Intelligent’ use of patient stories
at Board meetings
Patient Experience will provide a
focus and influence both the
quality and safety senior
walkabouts.
-
Patient stories and patient
experience will form a regular
part of every board meeting;
with evidence of the learning
that has come from them in
strategic decision making.
The role of patient and parent/
carer governor will be
strengthened
New PE key performance
indicators will be developed
-
27
-
Every service in the trust will be
using PE to identify
opportunities for improvement
and will implement at least one
patient experience improvement
project annually
Develop systems and
processes to provide feedback
to children, young people &
families and other
stakeholders both at service /
department and corporate
level.
-
-
Every ward/ departmental will
have an agreed minimum data
set display in place.
The display will have both parent
and be CYP focussed.
-
There will be a clear and
comprehensive presence of
patient feedback in all public and
clinical areas of the organisation.
Figure 18 BCH Patient Experience & Participation Objectives 2014-16
9. Learning from Francis, Berwick & Keogh
The impact of these key national reviews has been reported and considered at Trust Board and across
a wide range of operational and clinical forums and the Francis review formed the basis of our annual
InTent staff engagement event in September 2013. For each of the reviews we have considered the
overall implications and assessed the position of BCH against the key recommendations. This has
informed the developed our both our quality strategy and the patient experience strategy outlined
above. The assessment of BCH and the challenges presented to us are summarised in this section for
each of the reviews.
28
9.1. The Berwick Report
29
9.2. BCH Assessment against Berwick Recommendations
BCH has undertaken an assessment against the key recommendations developed within the Berwick report in order to assess and map our current priority
areas against the key recommendations and this is summarised below.
30
9.3. The Keogh Review
31
9.4. BCH Assessment against Keogh Review
We have also undertaken an assessment of our position in relation to the Keogh review and the key recommendations in order to establish whether our
strategy and priority areas for 2014-2016 are appropriately aligned.
32
10. The BCH People Strategy 2014-2016
As one of the UK‟s leading paediatric centres we go to great lengths to target, teach, nurture and
develop the skills of our present and future workforce, to enable access to training and education and
to foster life-long learning. Our aim is to ensure that all staff are appropriately equipped and qualified
for the work they do and continue to learn and develop in their time with us. We continually examine
our practice and look at ways to innovate and improve the service we all deliver so that our children,
young people and families receive a first-class service.
To support this we have developed our People Strategy which is a key enabler for supporting the
delivery of the overall Trust strategy. In developing our People Strategy we have considered a range of
national, regional and local factors.
10.1. National Factors
 The workforce supply chain is crucial and our intelligence tells us there will be less speciality
doctors available in the future but an increase in the numbers of GPs in training. As a Trust we
need to ensure we are exploiting this and providing a good training environment for medical
staff. Nationally there is a predicted 6% downward shift in the availability of junior medical staff.
 This will have a significant impact in some of our clinical specialties and how we respond to this
is critical to meeting our service demands and providing an excellent education experience.
Some initiatives we have developed include the extension of nurse led services such as the
development and integration of Advanced Nurse Practitioners and clinical site practitioners in
order to cover many tasks traditionally covered by junior doctors. We have also appointed 4
Physician Associates and 5 international doctors through the MTI scheme and in partnership
with a neighbouring trust
 The nursing workforce needs to grow significantly, nationally and regionally, and the predicted
supply will not meet this demand. We therefore need to create alternative roles to support the
gaps in qualified nursing staff. We are bringing in cohorts of Clinical Support staff and have
developed a robust programme and career framework for these staff. We are also looking at
advanced practice in other health care staff such as Pharmacy and we now have more people
who can prescribe which supports the junior doctor workforce.
 The national decisions around Pay will no impact on retention so we need to work to reduce
this risk and build resilience into structures.
 The requirement to grow seven day services will be a priority for the next couple of years and
we have commenced this in areas such as our support services directorate. The premium rates
will make this prohibitive in many cases so we must work with staff to develop a more flexible
approach
10.2. Regional Factors
 With changes in regional demographics it is predicted that Birmingham will become the second
plural city by 2024. Cultural competency in our workforce will be crucial to delivering quality
care that meets the individual needs of the communities we serve.
 The LETB & LETC structures have also developed significantly over the last year and have
improved the workforce planning process and education commissioning approval process so
that there is regional ownership of these key decisions.
33
 We have good relationships with education providers and are developing a proposal for joint
appointments to improve the quality of evidence based practice in curricular development
10.3. Achievements so Far
Our people strategy is a three year programme of work covering 2013-2016. We have already made
some significant progress during our first year across some of our core themes
Developing our People







Significant improvement in junior doctors induction
Improved education QA processes & highly commended deanery feedback
Development of the Youth Academy, traineeships and apprenticeship programme
New Intern programme- 25 completed or current interns
New leadership programme established
Launch of the Team Maker programme
A full review of Education and Learning functions completed
Caring for our People




Best ever response rate to the National Staff Survey - 22% increase
3% increase in overall staff engagement scores
Positive NICE audit on wellbeing services
A range of new wellbeing initiatives launched for staff
Managing our People
 Innovative workforce design solutions developed eg. Appointment of 4 Physician Associate & 5
International doctors.
 Through the „Future Fit‟ workforce project we have identified a number of productivity
opportunities which are being implemented with identified savings of £500k
 All junior rotas monitored and deemed fully compliant
 Workforce planning process embedded into business planning and improved information
available to support more effective education commissioning
 Improved recruitment processes- average appointment time reduced from 12 to 9 weeks
 Development of a robust assurance framework for all regulatory standards
10.4. Challenges for 2014-2016
With the launch of the Next Generation project there are a number of workforce priorities that we will
continue to focus on as we refresh the People strategy, these are:
1. Developing a mechanism that supports leaders to be compassionate and effective people
managers
2. Providing Organisational Development initiatives that continue to develop our culture and
improve staff involvement in the delivery of our services
3. Ensuring that we have a sufficient and appropriately skilled workforce supply
4. Developing a culture that supports staff to raise concerns
5. Ensuring that the pay bill is maintained within the reducing financial envelope
6. Leading the development of new health care roles that can support the delivery of new models
of care as part of the Next Generation project
As we move forward the challenges presented as a result of the financial pressures facing the NHS,
coupled with the need to deal with increased demand on our services, means that we also have to look
at changing the profile of our workforce in order to be able to deliver sustainable service models. This
is particularly challenging across some of our more specialised clinical areas such as PICU and
34
Oncology were we experience high attrition rates in our junior nursing workforce.
As part of the operational planning for 2014-2016 we have undertaken a detailed workforce profiling in
order to understand these workforce changes across our key staff groups. This has enabled us to
model and predict the required skill mix shift across each key area using the business planning data
provided by our front line clinical teams and intelligence regarding the future labour market. An
example of this approach is shown in figure 19 for our nursing staff and this methodology has been
used across all other key areas.
Figure 19: Workforce Scenario Modelling 2015-2019
10.5. Education & Training
The provision of high quality education and training is a fundamental part of our core business. We
have hundreds of health care professionals in training throughout the year and their experience is
critical to service delivery and our reputation as a teaching trust. As we move forward over the next few
years the need to develop and train new roles in response to the workforce challenges we face means
that the provision of high quality education and training becomes even more essential.
As a result we have undertaken a comprehensive review of our education and training provision during
2013 and developed our future strategy for 2014-2016. Within the strategy we have developed a
systematic process for redesigning roles around changing patient pathways; our challenge over the
next 2 years is to build this capability across the organisation. Pilot work, to test our workforce redesign
methodologies, has commenced, initially on our surgical pathways. Once these have been evaluated
and refined they will be more broadly utilised.
A college leadership team will be established and this will be made up of clinical leaders and
educationalists and they will jointly deliver the education strategy to ensure education and learning fully
supports workforce transformation. In summary our new approach to workforce development will see:
-
Education coming under a single umbrella to support skills- rather than profession- based
approaches to workforce development facilitating new models of care delivery
35
-
Focus on structured career frameworks to build resilience in supply chains across workforce
groups
New education quality dashboard aligned to regulatory and national education outcomes
New process to identify investment priorities for education and training aligned to delivering
workforce transformation at scale (figures 20 & 21)
Figure 20 Developing a Portfolio Model for Education & Training
36
Figure 21: Our Approach to Commissioning and Providing Education 2014-2016
11. Our Financial Plan 2014-2016
The Trust is forecasting to end 2013/14 with a surplus of £8m. This is £3.4m above its plan in year but
on a normalised basis the surplus is circa £6m. The Trust continues to perform strongly financially
having reported a Financial Risk Rating of 4 for Quarter 1 and 2 respectively and a Continuity of
Service Risk Rating of 4 in Quarter 3 with Quarter 4 expected to deliver the same.
Despite the strong historical performance of the organisation it is clear that the financial issues facing
the NHS as we move forward into 2014/15 are significant and these will present a tougher challenge to
BCH than in previous years. The forward look Income & Expenditure position indicates this and shows
a reducing surplus over the lifetime of this operational plan. (Figure 22).
Income and Expenditure [I&E]
Income from activities
Other income
Operating expenses
EBITDA
Interest receivable
Depreciation
Impairment
PDC dividend
Interest paid
Net Surplus / (deficit)
Forecast
Mar-14
£m
216.46
23.19
-222.89
16.77
0.13
-4.91
-0.69
-2.68
-0.49
8.13
Plan
Mar-15
£m
218.42
18.27
-224.58
12.12
0.13
-4.62
0.00
-2.94
-0.45
4.23
Plan
Mar-16
£m
215.79
18.52
-221.79
12.52
0.09
-5.29
0.00
-2.86
-0.45
4.01
Figure 22 Forward Look I&E Forecast 2014-2016
37
The challenge for the Trust is to maintain these levels of surpluses to enable medium term investment
in the estate as well as build up the longer term investment potential for a new hospital. In developing
the financial plan we have been conscious of balancing the need for future investment with the need to
ensure efficiency requirements remain at manageable levels. The key investments for the Trust have
been identified within the Estates section of this plan. The impact of these can be seen within the
Statement of Financial Position (figure 23).
Statement of Financial Position
Non-Current Assets
Current Assets excluding Cash
Cash
Assets, Total
Liabilities, Current
Net Current Assets (Liabilities)
Liabilities, Non Current
Total Assets Employed
Taxpayers' Equity:
Public Dividend Capital
Retained Earnings (Accumulated Losses)
Revaluation Reserve
Total Taxpayers Equity
Forecast
Mar-14
£m
102.15
17.37
42.85
162.37
-30.24
29.98
-6.34
125.79
Plan
Mar-15
£m
112.86
24.29
35.93
173.08
-29.70
23.26
-6.09
137.28
Plan
Mar-16
£m
134.33
42.08
18.14
194.56
-28.92
6.23
-6.54
159.10
86.22
26.80
12.77
125.79
86.22
31.03
12.77
130.02
86.22
35.03
12.77
134.02
Figure 23 Statement of Financial Position 2014-2016
As the constituent parts of the Medium Term Clinical Strategy are developed the impact of the
increasing non-current asset base can be seen on the Trust‟s cash balance which reaches its lowest
point in 2015/16. The cashflow movements highlight the investment programme (figure 24).
Cashflow
Opening Balance
Movements:
Surplus/(Deficit) from operations
Increase/(decrease in working capital
Property, plant and equipment
Net cash inflow/(outflow) from financing
Net cash outflow/inflow
Closing Balance
Forecast
Mar-14
£m
36.17
Plan
Mar-15
£m
42.85
Plan
Mar-16
£m
35.93
15.70
3.74
-10.22
-2.55
6.68
42.85
9.82
-0.89
-13.03
-2.81
-6.92
35.93
9.97
-0.77
-24.22
-2.77
-17.79
18.14
Figure 24 Cashflow Profile 2014-2016
The revenue impact associated with increasing the Trust‟s infrastructure is also highlighted in the I&E
position as clinical income rises significantly over the period despite tariff reductions being forecast.
The aims of the Trust‟s financial strategy remain to:
-
Improve the quality of service that reduce variation, waste and harm;
Provide the resource to deliver world class patient centred care;
Provide the funding for a productive, motivated and professional workforce;
Provide better value for money; and
Deliver affordable, world class health services for children and young people.
The strategy will be delivered through the following six components:
1. Using a mixed funding strategy for major new infrastructure investment;
38
2.
3.
4.
5.
6.
Developing a clear financial framework – to monitor financial stability and investment;
Delivering the necessary efficiency savings through traditional and transformational routes;
Improving financial literacy across the organisation;
Developing NHS and non-NHS business opportunities; and
Recognise charitable funds as a core component of the funding mix.
The key risks to achieving the Trust‟s financial strategy are outlined below and these will be picked up
in the Trust‟s downside scenario.







Ability to finance the Medium Term Estates Strategy;
CIP delivery;
Funding Reductions
o Move to Education Placement rates and then to Education Reference Costs
o Future uncertainty over the paediatric top-up, with the NHS England and Monitor review
of funding specialised services ongoing
o Loss of Community CAMHs funding and further public sector funding reductions;
Cost of Clinical Negligence Scheme for Trusts contributions;
Cost of maintaining the retained estate;
External commissioning environment changes; and
Reforming the Trust‟s Workforce.
11.1. Income
The 2014/15 income included in the financial plan is based on provisionally agreed contracts with
commissioners and anticipated contractual positions.
At the time of writing the position with the Trust‟s 2 main Commissioners is as follows:


NHS England – agreement of contractual value - £158.8m. This accounts for 73% of the Trust‟s
clinical income portfolio; and
Birmingham South Central CCG and Associates – basis of contract agreed.
Commissioning- contracts have largely been based on out-turn activity with the major development
being the agreed income associated with the further expansion of PICU to 31 beds in a full year from
2015/16. Agreements with NHS England for 2014/15 have seen the Trust fall into line with contracting
conditions imposed throughout England. This has seen funding reductions for Chemotherapy and
Major Trauma.
During the course of the Trust‟s business planning process we undertook a clinically led „bottom-up‟
approach with individual specialties engaged in modelling their activity projections. This provided the
basis for our corporate assumptions recognising that due to capacity constraints the realisation of
these will not be possible until the mid-term of the 5 year planning period once the Trust‟s proposed
estate development has been completed.
CAMHs- a key risk in the Trust‟s future financial plan is the long-term future of the Community CAMHs
service. The Birmingham Cross-City, Birmingham South Central and Sandwell and West Birmingham
CCGs are currently tendering a Community Mental Health Service for under 25 year-olds across
Birmingham. A key part of this is the Trust‟s CAMHs Community service for which the Trust presently
receives £9.6m, of which £8.2m is recurrently funded. Commissioners have provided 18 months
(£2.1m) of non-recurrent funding for the part of this service which was previously financed by
Birmingham City Council. The full-year funding (£1.4m) is not part of the existing financial envelope of
39
the services being tendered. A decision on the successful applicant is due by February 2015 with
mobilisation of the new service by 1 October 2015. The operational plan assumes that the Trust will be
successful in being awarded the Community CAMHs contract.
The key drivers of income in the Trust‟s plans are:
-
Tariff;
Growth;
CQUIN;
PICU growth; and
New drug charges.
Tariff-we have assumed a tariff reduction in 2015/16 based on the planning assumptions included in
Monitor‟s “Guidance for the Annual Planning Review 2014/15”. Specifically for the Trust we have not
assumed any changes to the two-tiered system of funding for the Paediatric Top-Up.
Other key changes to the tariff that have impacted upon the Trust are:


Further local adjustments to CF year of care tariffs; and
Unbundled diagnostics.
Growth- We have assumed limited growth throughout the course of the plan although given historical
activity levels this may be a prudent approach. This in part is down to the existing capacity constraints.
The medium-term plan will build in more of the specialty by specialty assessments of growth. Any
predicted growth levels will not trigger contractual clauses that will impact upon the Trust‟s ability to
cover its costs in delivering this additional activity.
CQUIN- The national 2.5% CQUIN level means that the Trust has the opportunity to receive circa
£4.5m through this route. The Trust‟s plans assume that the majority of this is recovered and is putting
in specific resource to ensure that this is achieved. The Trust was successful in receiving 100% of
CQUIN monies in 2012/13 and remains on course for a similar outcome in 2013/14.
PICU- The Trust is on an agreed PICU bed development path which has seen incremental increases in
the number of beds commissioned. Although physical bed capacity is available the Trust does not
expect to be operating at its 31 bed capacity until 2015/16. The agreed level of funded PICU beds in
2014/15 remains 29.5 with performance variations adjusted for at a 50% marginal rate.
New Drug Charges- The specialist nature of the Trust‟s mandatory services has seen a consistent
increase in the income levels generated through non-pbr other activities. The majority of these rises
are deemed “pass-through” items ie the Trust incurs the cost and invoices Commissioners the
equivalent amount to ensure cost neutrality. Although no further growth has been built in from the
Trust‟s perspective an increasing percentage of items of this nature applies downward pressure to the
EBITDA and I&E Surplus Margins. The Trust remains committed to working with our health economy to
reduce the overall cost burden of this area of the contracting portfolio. This builds on from the
successful opening of the Trust‟s Outpatient Pharmacy subsidiary, the Medicine Chest, in January
2013.
Away from Clinical Income the Trust‟s levels of Education and R&D income are reducing. The level of
CLRN funding reduced further in 2013/14 but the Trust is now expecting a flat funding profile going
forward.
40
The transition towards tariff based education income commenced in 2013/14 with NMET and SIFTS
moving to a placement methodology and this has advanced further in 2014/15 with the full impact of
those changes being incurred plus the first year of MADEL changes. The combined cumulative loss for
the Trust over the duration of this planning period is £0.5m in 2013/14, £1.0m in 2014/15 rising to
£1.3m in 2015/16. The Trust will be pushing for local flexibility support from HEEWM as this funding
methodology is punitive for specialist hospitals. Looking further forward, the Trust has been actively
supporting the DH on the Education Reference Cost project so will be well placed for future collection
exercises.
11.2. Costs
The cost base of the Trust is predicated on delivering the same levels of activity in 2014/15 as 2013/14
whilst delivering efficiencies sufficient enough to remove the impact of pay and price inflationary
pressures and any significant one-off costs. The plan for 2014/15 retains a forward look given the
expected “cliff-face” of increased costs in 2015/16 so part of the financial planning approach has been
to smooth out the transition between the 2 years.
Inflationary pressures are once again based on the planning assumptions outlined in Monitor‟s
“Guidance for the Annual Planning Review 2014/15”. The Trust has assumed 1% national pay growth
in each of the future years plus localised impacts of Agenda for Change and Consultant Contract
seniority. The assumptions are as follows:
Pay
Drugs
Clinical Supplies
Other Costs
2014/15
1.50%
3.00%
3.00%
3.00%
2015/16
1.50%
3.00%
3.00%
3.00%
Figure 25 Cost Assumptions 2014-2016
The financial plan for 2014/15 has built in non-recurrent funding to facilitate the extensive
transformation programme that the Trust will be undertaking. In addition to this the Trust has sought to
pump prime developments during 2013/14 which will enable the minimisation of costs and the
maximisation of savings during 2014/15.
From 2015/16 the Trust will see increasing financial pressures on 2 fronts:
- Changes to employers‟ pension contributions
- Changes to the charging methodology for CNST
The latter is more specific to the Trust as the current charging methodology provides with the Trust
with a 30%, equivalent to £1m, rebate as allowed upon reaching NHSLA Level 3. The worst case
scenario is that the Trust will lose the full benefit of this. Although the new methodology has not yet
been communicated some of the contributory factors are known and it is likely that the Trust‟s
contributions will increase in 2015/16.
11.3. Local Cost Pressures
As in all previous financial years there are a number of localised cost pressures being experienced by
the Trust. A cost pressure reserve has been set aside to fund those pressures that are deemed a
clinical priority. In 2014/15 these include supporting the IT infrastructure to allow the implementation of
the Trust‟s IT strategy, Infection Control, Nurse Staffing and ERA.
41
Work is progressing to identify the impact of seven day services at the Trust. Following on from “NHS
Services Seven Days a Week – Summary of Initial Findings” the Trust has been using the HFMA
template to assess this impact. As with a number of other organisations seven day services have
incrementally been developed at the Trust although the overall financial plan assumes any further
expansion will be cost neutral.
As per previous years the Trust has built flexibility, albeit at a lower level than 2013/14, into the I&E
position by way of a contingency reserve. Non-utilisation of this will deliver a higher in-year surplus as
per the experience of 2013/14.
11.4. Capital Expenditure
The Board approved the financial strategy in March 2012. This indicated that given the cost of capital
and the continuing global banking and sovereign debt crisis, traditional bank and bond funding alone,
that have underpinned funding mechanisms such as the Private Finance Initiative, will not be
affordable. This means that if the Trust is to develop an infrastructure to compete successfully over the
longer term in local, regional and national paediatric markets it has to develop a financing plan that is
affordable and sustainable through using a range and combination of sources.
The 2014/15 capital programme has been developed in this context and will have to work within the
resource envelope set out in the Trust financial strategy. The Trust‟s Capital Programme has been
derived via the following process:



Specialty and Corporate Department Business Plans outlining capital requirements for the
medium term;
Identification of trust-wide capital requirements that fell outside of specific specialty plans; and
Prioritisation process through nominated Executive.
The single largest element of the capital programme over the duration of the operational plan will be
the planning and initial works on the new clinical block on the Steelhouse Lane site. The £35m set
aside for developing the site will be spread over 2014/15-2016/17 and will be linked to the Trust‟s
fundraising strategy. Prior to this the Trust has a number of short-term plans which will deal with
immediate capacity issues, which are a combination of revenue and capital schemes. The capital
associated with the immediate operational plan was contained within the 5 year Capex Forecast
submitted to Monitor in January 2014.
Capital Expenditure
New Build
Maintenance - Routine Non-Backlog - locally Funded
Maintenance - Backlog - Locally funded
Maintenance - Backlog - DH Funded
Equipment
Information Technology
Other
Gross Capital Expenditure Including IFRS Impact & Asset transfers
Disposals and Transfers
Grants and Donations
Net Capex against Health Budget incl IFRS impact
Plan
Plan
Mar-15 Mar-16
£m
£m
4,775
19,901
500
500
1,500
1,500
0
0
2,250
2,500
5,397
1,578
910
790
15,332
26,769
0
0
(2,300)
(2,550)
13,032
24,219
Figure 26 Forecast Capital Expenditure 2014-2016
42
Outside of the new clinical block development the other key aspects of the programme are:
- Phase One of the CAMHs Tier IV development (2014/15) and agreeing Phase Two of the
development (2015/16);
- Continued implementation of the IT Strategy (assisted by funds received from the Safer
Hospitals, Safer Wards Technology Fund - Wave One and charitable monies for the
development of an e-prescribing system);
- CT scanner and Gamma Camera projects concluded;
- Adding additional physical capacity at the Steelhouse Lane site;
- Backlog estates maintenance programme; and
- Replacement medical equipment programme including replacing one of the Trust‟s 3 MRI
scanners in 2015/16.
Other schemes that have been approved include:
- Patient experience projects;
- Minor building projects; and
- Front of house development.
Further strategic capital schemes have not been included in the figures above as they are yet to be
approved at Finance and Resources Committee and Board of Director level. Business cases will be
expected to be received during the year for these and may include a buying-out the existing
arrangement with Riverside Housing.
11.5. Liquidity
The Trust enters the operational planning period with a strong liquidity position. The cash balance
retained with Government Banking Services at 31 March is anticipated to be in the region of £43m.
This is an increase of £6.7m on 2012/13.
The planned annual surpluses of £4m will enhance this further. However, the planned investment in
the estate over the operational planning period will see this reduce to £18m by March 2016. The
Programme Board set up to progress the Estates Strategy will develop a funding approach for the
medium and long-terms. This may alter the current funding approach which is to finance the Clinical
Build through a combination of internally generated funds and fundraised monies.
11.6. Risk Ratings
The Risk Ratings associated with the baseline operational plan are outlined in figure 27.
Continuity of Services Risk Rating
Forecast
Mar-14
£m
Plan
Mar-15
£m
Plan
Mar-16
£m
Metric:
Liquidity Days
36.8
42.0
31.7
Liquidity Metric
4
4
4
Capital Servicing Capacity
5.0
2.9
3.0
Capital Servicing Metric
4
4
4
Overall Rating
4
4
4
Figure 27 Forecast Continuity of Service Risk Ratings 2014-2016
The liquidity days declines over the duration of the operational plan as the capital programme
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intensifies whilst the Capital Servicing metric reduces from its high point in 2013/14 as the I&E surplus
and associated EBITDA levels reduce by over £3.5m.
Sensitivity of Risk Ratings- the resilience of the Trust‟s Risk Rating varies by CoSRR metric. In the
operational period £18m less cash could be accommodated without the Liquidity Metric reducing to a
4. However, a reduction in the Trust‟s EBITDA margin of £1.4m would cause the Capital Servicing
Metric to reduce to a 3. This would still give the Trust an overall CoSRR of 4.
For the Capital Servicing metric to reduce to 2 and therefore result in the overall CoSRR reducing to a
3 the EBITDA position would have to reduce by £4.25m which would lead to the Trust‟s planned
surplus being fully eradicated. This is the equivalent of CIP delivery falling 50% short of plan whilst all
flexibility is also used up.
11.7. CIP Governance
As part of the operational planning for 2014-2016 there has been a significant shift towards developing
a more transformational approach to the delivery of Cost Improvement Programmes (CIP). The
historical performance of NHS Trusts across the FTN sector and the past performance of BCH against
annual CIP targets is an important factor for moving towards a more transformational approach. The
historic CIP performance for The Trust is illustrated below in figure 28.
Plan £k
Actual £k
Shortfall £k
% Delivered
2010/11
5,559
5,313
-246
-4%
2011/12
9,488
9,212
-276
-3%
2012/13
10,730
8,118
-2,612
-24%
2013/14
8,436
5,358
-3,078
-36%
Figure 28 Historic CIP deliver BCH 2010-2014
This shows a deteriorating level of achievement over the past 2 years due to an increasing overreliance on traditional CIP programmes and cost-cutting rather than the development of a more
sustainable and transformational programme of service improvement and redesign. This approach
and the need to change is put into further context when we consider the scale of the future CIP
programme that will have to be delivered over the next ten years based on our analysis of future I&E
(figure 29).
Figure 29 Predicted I&E Modelling BCH 2014-2024
Building on the Trust‟s forecast outturn position we have tracked Monitor‟s assumptions around the
level of efficiency required on an annual basis, but also assumed levels of inflation and key financial
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pressures. At the end of the Monitor ten year planning period the Trust will have had to bridge a
financial gap of £46million, equivalent to 19.7% of current costs simply to break-even. In addition if the
Trust is to invest in the current site and build up the financial reserves to afford a new hospital the
£46million increases to over £76 million.
In generating the financial plan an overall CIP target of £9.07m is required in 2014/15. This
incorporates legacy CIPs carried forward from 2013/14 and if achieved alongside the Directorate
rebasing process will ensure balanced financial positions across the Trust. The difference in approach
for 2014/15 and 2015/16 is to have a two-tier programme eg for 2014/15:


Hospital wide schemes account for £4.24m;
Directorate specific schemes account for £4.83m of which £3.86m must be cost reducing or
non-clinical income generating. This will have a more traditional CIP focus and have been
worked up by Directorates since the launch of the business planning process in late 2013. For
these schemes it is seen as a vital shift in emphasis away from clinical income generating
schemes to ones of cost and cash releasing.
The hospital wide schemes will be based on 5 themes and form part of the Next Generation project
phase 1.
-
Transformation;
Workforce;
IT Strategy;
Back to Basics; and
Commercial and R&D.
11.8. Transformation
The options for supporting our programme of transformation in terms of the way in which we provide
services have been examined in detail. After undertaking a detailed analysis the most effective
method was to appoint external experts supported by a small internal team. The external support
provides us with a new set of skills and tools and working alongside our internal team will ensure the
skills are embedded across the organisation.
We have chosen Newton to be our partner in developing this work and this is based on an initial
diagnostic of four potential areas- two of these, theatres and outpatients, will form the basis of our work
going forward. In each area our early work shows the potential to deliver additional capacity through
examining how we organise the processes and flow through each service area. Freeing up this
capacity will reduce the need for significant premium time working and will help in meeting the
increased demand for services outlined above. Our estimates of the financial benefits associated with
this work are £3million per annum.
The Newton team will begin work in late March 2014 and will be on site for between seven and nine
months. However, these are only two of four areas that our transformation team will be examining in
2014/15, the other two areas being drugs spend and usage and pre-assessment of patients.
11.9. Workforce
In 2013/14 the Trust set aside £1.25million to examine new ways of working. The purpose of this
funding was to address the need to change our skill mix, fill hard to recruit areas and also meet the
efficiency challenge that we face. The latter is driven by simple economics in that we can‟t address
continued efficiency requirements without reducing labour costs that represent 65% of our cost
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structure.
The £1.25million invested last year was in recognition that this would take longer than a year and the
results had to be substitution of new roles rather than additionally and would need to release cash. The
funding was predominantly non-recurrent so a failure to secure these changes would add cost
pressures back into the Trust‟s finances. The second element of the workforce was looking at a range
of terms of condition issues – at a basic level ensuring that we work to these but then based on a piece
of work undertaken by KPMG looking at whether it is possible to develop some alternatives. Changes
to national terms and conditions have delivered some savings in 2013/14 but widening these to local
agreements will be necessary in future years.
11.10. Information Technology
The Board of Directors agreed the IT strategy in 2013. The financial impact of implementing this has
been assessed and will form a key strand of the overall CIP programme between 2014-2016. The work
undertaken in developing and costing the strategy was crucial in the successful bid submitted to the
national technology fund to secure additional funding. The estimated benefit in 2014/15 is £0.48million.
Achieving this will not be easy and will require some difficult decisions to be made around the scale,
scope and role of staff currently undertaking clinical administration.
11.11 Back to basics
This is a wide-ranging piece of work that covers areas from non-pay procurement savings through to
tightening of authorisation controls and further financial training of all staff. In terms of procurement we
are going to rationalise the procurement catalogue with the target being to reduce non-pay inflation
next year to zero (set by the national procurement strategy). This will save approximately £0.6million.
Other aspects of the Back to Basics workstream include:



Avoiding contractual penalties for missing quality targets/indicators;
Ensuring 100% achievement of CQUIN targets at minimal enabling cost; and
Avoiding readmission income losses.
The overall back to basics campaign will be extended to other areas during 2014-2016.
11.12. Commercial and R&D
This workstream will examine how we might leverage our position as a specialist paediatric provider
both in terms of improved research and development income (and contribution) and other commercial
opportunities. The most obvious component is private patients and this will be looked at as part of the
site development plans. Capacity constraints realistically mean that any growth in this area is limited
before that point.
In 2014/15 the trust-wide targets are broken down as follows:
Technology workstream
Workforce Future Fit
New Ways of Working
Theatres and Outpatients Transformation
Back To Basics – Procurement
Reduction in contract penalties
Drug spend reduction
TOTAL HOSPITAL WIDE SCHEMES
2014/15 £m
£0.48
£0.57
£0.20
£0.96
£0.60
£0.93
£0.50
£4.24
Figure 30: Summary of Trust Wide CIP Programmes by Theme
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Following the external review by KPMG the Trust will also be strengthening its Project Management
Office (PMO) function during 2014/15. This will be in place by July 2014 and will work in conjunction
with the transformation team.
11.13. Management of CIPs
The long-term financial plan sets out the level of cash releasing efficiencies required over the medium
term. The average level of efficiency is similar to that of peer organisations which gives some
assurance that the levels required are in line with the broad assessment across the sector. The
Finance & Resources Committee receives regular financial reports that reflect on progress against the
CIP plan and also test the feasibility of future plans.
The achievement of long-term efficiency savings is recognised as one of the core strategic risks on the
Board Assurance Framework, which is reviewed on a regular basis by the Board and also reviewed in
more depth at the Audit Committee. Directorate CIP delivery is reviewed monthly against targets and
corrective action and support, where necessary, agreed to ensure recovery. Monthly Resources
reports, produced for the Board of Directors and Finance and Resources Committee, will include a KPI
of CIP against target and the detail behind this.
As part of the management processes for delivering CIP programmes in 2014-2016 there are a range
of key principles around which they are organised:
-
Each scheme has a specific PID, managerial and clinical lead
Clinical engagement is central to the design and delivery of many of the schemes
Each scheme is risk assessed through a quality impact assessment, which is signed off by a
local clinical leader as well as the Chief Medical Officer and Chief Nursing Officer.
Each scheme is risk assessed for delivery with key dependencies identified
Schemes are tested against the Trust's strategic objectives.
*****END OF DOCUMENT*****
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