2014 - 2019
Version: 3.1
Last Modified: 9 March 2016
Status: Approved
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Contents
1
EXECUTIVE SUMMARY ........................................................................................................................... 5
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12
2
TRUST PROFILE ..................................................................................................................................... 18
2.1
2.2
2.3
2.4
2.5
2.6
3
THE HEALTH & SOCIAL CARE ECONOMY IN WHICH DCHS OPERATES ................................................................ 28
DEMOGRAPHIC ANALYSIS AND HEALTH NEEDS............................................................................................... 30
GENERAL CHANGES IN THE LOCAL HEALTH ECONOMY ..................................................................................... 31
PROVIDER LANDSCAPE .............................................................................................................................. 33
COMMISSIONING LANDSCAPE ..................................................................................................................... 36
EXTERNAL ENVIRONMENT .......................................................................................................................... 43
STRENGTHS, WEAKNESSES, OPPORTUNITIES AND THREATS .............................................................................. 50
STRATEGY ............................................................................................................................................ 56
4.1
4.2
4.3
4.4
4.5
5
OVERVIEW.............................................................................................................................................. 19
DCHS SERVICES ...................................................................................................................................... 20
THE DCHS ‘WAY’ .................................................................................................................................... 20
MAIN COMMISSIONERS ............................................................................................................................. 21
WORKFORCE AND ORGANISATIONAL STRUCTURE ........................................................................................... 23
HISTORICAL PERFORMANCE ....................................................................................................................... 25
THE ENVIRONMENT IN WHICH DCHS OPERATES .................................................................................. 28
3.1
3.2
3.3
3.4
3.5
3.6
3.7
4
INTRODUCTION .......................................................................................................................................... 5
VISION AND VALUES.................................................................................................................................... 5
ENVIRONMENT IN WHICH DCHS OPERATES ..................................................................................................... 6
STRATEGY ................................................................................................................................................. 8
RATIONALE FOR NHS FOUNDATION TRUST STATUS ......................................................................................... 11
SERVICE DEVELOPMENT PLANS ................................................................................................................... 12
QUALITY................................................................................................................................................. 13
FINANCIAL PLANS ..................................................................................................................................... 14
KEY RISKS ............................................................................................................................................... 15
PEOPLE & ORGANISATIONAL EFFECTIVENESS .................................................................................................. 15
GOVERNANCE ARRANGEMENTS ................................................................................................................... 16
SUMMARY .............................................................................................................................................. 17
CONTEXT ................................................................................................................................................ 56
VISION ................................................................................................................................................... 56
STRATEGIC OBJECTIVES ............................................................................................................................. 57
APPROACH TO BUSINESS DEVELOPMENT ...................................................................................................... 62
TOWARDS FOUNDATION TRUST STATUS ....................................................................................................... 66
SERVICE DEVELOPMENT PLAN.............................................................................................................. 70
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
FRAIL ELDERLY ......................................................................................................................................... 71
OLDER PEOPLE’S MENTAL HEALTH (OPMH) ................................................................................................ 81
LEARNING DISABILITY................................................................................................................................ 83
HEALTH, WELLBEING AND INCLUSION .......................................................................................................... 87
PLANNED CARE........................................................................................................................................ 93
SUPPORT SERVICES ................................................................................................................................... 99
SERVICE DEVELOPMENT PROCESS.............................................................................................................. 101
ESTATE STRATEGY .................................................................................................................................. 104
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5.9
6
QUALITY ............................................................................................................................................. 111
6.1
6.2
6.3
6.4
6.5
6.6
6.7
7
DCHS BOARD ....................................................................................................................................... 176
WORKFORCE PROFILE ............................................................................................................................. 178
TEMPORARY STAFF ................................................................................................................................. 180
TURNOVER ........................................................................................................................................... 180
RECRUITMENT ....................................................................................................................................... 180
ATTENDANCE ........................................................................................................................................ 181
WORKFORCE TRANSFORMATION PROGRAMME............................................................................................ 181
PEOPLE STRATEGY .................................................................................................................................. 183
ENSURING DELIVERY ............................................................................................................................... 189
MONITORING PROGRESS ......................................................................................................................... 190
RISKS AND MITIGATION........................................................................................................................... 190
GOVERNANCE ARRANGEMENTS ........................................................................................................ 192
10.1
10.2
10.3
10.4
10.5
10.6
10.7
11
SUMMARY OF KEY ORGANISATIONAL RISKS ................................................................................................. 157
SENSITIVITY ANALYSIS ............................................................................................................................. 166
PEOPLE AND ORGANISATIONAL EFFECTIVENESS ................................................................................ 175
9.1
9.2
9.3
9.4
9.5
9.6
9.7
9.8
9.9
9.10
9.11
10
INTRODUCTION ...................................................................................................................................... 124
HISTORICAL FINANCIAL PERFORMANCE ...................................................................................................... 125
FUTURE PLANNING ASSUMPTIONS ............................................................................................................ 133
FINANCIAL PLANS – 4TH REFRESH 2014/15 TO 2019/20 ........................................................................... 140
SENSITIVITY ANALYSIS ............................................................................................................................. 153
PREPARATION FOR FOUNDATION TRUST STATUS .......................................................................................... 153
RISKS .................................................................................................................................................. 157
8.1
8.2
9
HOW ................................................................................................................................................... 112
QUALITY SERVICES - THE NATIONAL CONTEXT ............................................................................................. 112
QUALITY SERVICES –THE LOCAL CONTEXT................................................................................................... 115
THE QUALITY JOURNEY – ‘THE DCHS WAY’ .............................................................................................. 116
THE DCHS QUALITY GOVERNANCE FRAMEWORK......................................................................................... 119
QUALITY IMPROVEMENT ......................................................................................................................... 119
QUALITY GOALS AND OUTCOMES OF SUCCESS ............................................................................................. 122
FINANCIAL PLANS............................................................................................................................... 124
7.1
7.2
7.3
7.4
7.5
7.6
8
IM&T STRATEGY ................................................................................................................................... 105
CORPORATE GOVERNANCE AND MANAGEMENT ............................................................................................ 192
STAKEHOLDER INTERESTS ......................................................................................................................... 195
RISK MANAGEMENT ............................................................................................................................... 201
PERFORMANCE MANAGEMENT REPORTING FRAMEWORK ............................................................................... 203
FINANCIAL CONTROLS AND REPORTING ....................................................................................................... 204
AUDIT ARRANGEMENTS .......................................................................................................................... 204
PROVIDER LICENSE: ................................................................................................................................ 206
APPENDIX A - ABBREVIATIONS ........................................................................................................... 207
NOTE: APPENDICES REMOVED FOR COMMERCIAL REASONS
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1
1.1
Executive Summary
Introduction
This document forms the third refresh of the DCHS Integrated Business Plan. This
has been built on a thorough review of the context within which the organisation
works, continuing close and effective dialogue with all its commissioners and
stakeholders and especially with its staff and users.
The revised plan is also built on a foundation of continued delivery of high quality
services underpinned by a sustainable business model. DCHS is progressing
through the final stages of its Foundation Trust application, having received very
positive feedback from both Monitor and the CQC; Monitor highlighted how DCHS is
well led with good governance processes and financial viability; CQC emphasised
the commitment of staff to the delivery of the values of the organisation through the
provision of high quality compassionate care and of the competence of the Board
who are well connected with the services and the patients served.
The service models developed within this latest version of the strategy are the
product of joint working and co-design with commissioners and are already being
delivered through a number of innovative service developments. The key service
challenges relate both to increased partnership working to deliver new and
increasingly efficient ways of providing integrated care as well as to increasing
competition as a number of current DCHS services are put out to tender. The plan,
however, reflects the capability DCHS is developing to cope in this developing
commercial market and highlights a number of tender successes upon which it can
build. The intention is that the plan should convey the aspiration of DCHS to remain
a provider of choice and effective partner within all the communities it serves and an
organisation that is looking to grow its reputation and commercial portfolio whilst
remaining flexible and responsive to the rapidly changing context in which it operates
and with which it will continue to engage.
1.2
Vision and values
Since DCHS’ inception, we have worked hard to develop the organisation’s culture
and values, strengthen leadership and engage with staff and key stakeholders to
develop and realise our vision of being the best specialist community services
provider of local healthcare and a great place to work.
This vision, our values and overarching ambitions have been captured in the ‘DCHS
Way’ which defines a core set of characteristics, behaviours and values which
underpin everything we do and is set out below
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In essence, DCHS aims to provide personalised and safe care, promote the health
and well-being of all, enhance the life chances of many and promote independence
and opportunity wherever possible. We are the only organisation locally with the
aspiration and specialist expertise to provide the sorts of care which people need,
every day, if they are to be looked after in or as near to their home as possible.
1.3
Environment in which DCHS operates
The Trust has undertaken a thorough market and competitor analysis which has
informed much of the IBP and in particular the strategy, service development plans
and financial assumptions.
This analysis entailed a detailed review of:
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The major demographic changes across Derbyshire;
The key policy drivers nationally and locally;
A long term financial analysis of the health and social care community
nationally and locally;
The financial contribution made by the main service lines;
Detailed feedback interviews with the Trust’s key partners including GP
Commissioners, the county council and local acute and mental health Trusts;
A detailed analysis of potential competitors;
A review of commissioning intentions.
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The Board has undertaken a thorough external Political, Economic, Social,
Technological Legal & Environmental (PESTLE) and internal organisational
Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis. Detailed
responses are shown in section 3, and have informed the plans contained throughout
the document.
This final version of the IBP has also taken into account the feedback from the
community foundation Trust consultation which is attached at Appendix E
Key issues
Key issues which arose from our PESTLE and SWOT analysis and which the Trust
wishes to address over the life time of the IBP are:
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To provide high quality care that provides a positive patient experience.
The changing needs of our population, particularly our increasing frail elderly
population, and the increasing requirement to make ’ every contact count’ by
continuing to shift the emphasis of our services towards promoting good
health, maximising independence and focusing on outcomes as described in
the 3 NHS Outcomes Frameworks1. See section 5 Service Development
Plans.
The need to make our services more integrated and easier to access so that
for patients and referrers the default position is in the community rather than in
acute care, moving away from a plethora of different teams with different titles
and access arrangements, aligning our services around service users and
patient pathways. See section 5 Service Development Plans;
Reduced variance and continuous improvement in quality, responsiveness
and accessibility to the full range of the population - in particular moving away
from such a reliance on inpatient facilities to much more developed multidisciplinary / multi-agency teams supporting care in or near people’s homes
where appropriate. See section 5 Service Development Plans;
A more flexible workforce so that we can respond effectively to fluctuation in
demand and also to new market opportunities. This will be of critical
importance in responding to the future tenders and other initiatives. See
section 8 People & Organisational Effectiveness;
Improved and rationalised estate and support services, including our IM&T
capability support thus enhancing value for our clinical services, supporting the
patient pathway. See section 5 for more details of our Estate and IM&T
Strategies;
Work at an individual patient and at organisational level to develop integrated
services and supply chains with partner organisations within and without the
NHS. See section 5 Service Development Plans;
Development of sustainable partnerships to maximise opportunities and
service outcomes. See section 5 Service Development Plans;
1
NHS Outcomes Framework, Public Health Outcomes Framework and Adults and Social Care
Outcomes Framework
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

1.4
The on-going commercial development of the business through improving the
quality of our services and our people along with our business systems so the
Trust is responsive and successful in an increasingly competitive environment.
This is reflected throughout the IBP.
The need to meet the Social Care Challenge in an ever more difficult
financially challenging environment
Strategy
The Board has made the development of our strategy a major priority in its work
programme with a real focus on involving patients, staff and other partner
organisations in its development. The resulting plan has built upon the organisation’s
strengths, our understanding of our local populations and the external environment in
which we operate informed by our market and competitor analysis.
Our strategic objectives reflect the DCHS Way and have been developed over a
number of years in conjunction with our staff and as a result of lengthy debate at
Board level:
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To deliver high quality and sustainable services which echo the values and
aspirations of the communities that we serve (Quality Service);
To build a high performance work environment which engages, involves and
supports staff to reach their full potential (Quality People);
To ensure an effective, efficient and economical organisation which promotes
productive working and which offers good value to its community and
commissioners (Quality Business).
Specialist community services provider Trust
Underlying our strategy has been a fundamental debate about why the Trust should
exist. We believe passionately, supported by our commissioners, primary care and
council colleagues, staff and many other partners too, that a specialist community
services provider Trust is an invaluable part of the local health and social care
community because it is unique in:
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Being the only organisation operating across the County which has at its heart
the provision of community services and so is able to co-ordinate the on-going
care for those patients being discharged from the 13 acute Trusts in and
around Derbyshire;
Having the skills to care for people who may require a range of support from
an on-going long term relationship in their home to an outpatient appointment
in one of our treatment centres;
Aiming to not just provide care but also promote the health and well-being of
all, promoting independence and opportunity wherever possible;
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Being able to meet a significant patient service gap between certain patient
groups’ need for urgent care and an acute referral. This includes patients with
long term conditions and elderly confused patients.
Through the provision of a range of consistent and coherently managed
integrated services, providing high quality patient services;
o Without the need of a bed
o Close to home
o Without the additional expense of domiciliary services
Being able to act at individual patient and care pathway level as care coordinator /supply chain manager across the statutory and voluntary sector to
deliver ever more integrated care for patients and their families as evidenced
by the Kings Fund and Nuffield Trust2;
Having critical mass to provide specialist community services
Planning to offer a well organised range of services delivered from effective
treatment centres which will enhance community provision and lower the cost
of healthcare delivery for patient groups where demand is growing leading to
increased potential cost to the NHS;
Being able to deliver these services in a flexible way so that we can respond to
the differing characteristics of the populations we serve and support our
commissioners to provide effective local solutions.
Acting as an important part of commissioners’ market management strategy in
providing an alternative choice of provider for patients and referrers.
Making healthcare easier – the picture in 5 years
We have thought carefully about what our services and our organisation will look like
in 5 years’ time when this IBP has been implemented. What matters most is the
experience of our patients and their families and carers. Currently, we have pockets
of excellent practice. By 2019, the variation in care models has been eradicated.
There are many examples which could be given, but the 2 patient stories below paint
this picture more clearly than anything else can.
In 2014, Annie, the 78 year old who fell in her garden one Friday evening, spent
more than 2 weeks in an acute hospital 12 miles away from home and a further 2
weeks in a community hospital and her daughter found it impossible to visit her. In
2019, the GP rings the single point of access which arranges for her to be assessed
in a local assessment and diagnostic centre where her physical and mental health
needs are addressed. She is admitted to a treatment centre for just one day before
being discharged to be looked after by one of the new multi-agency integrated
community care teams. The team, supported by telecare, and with Annie’s daughter,
have successfully looked after Annie in her own home for 7 months.
Where next for the NHS reforms? The case for integrated care – Available from:
http://www.kingsfund.org.uk/publications/articles/nhs_pause_paper.html
2
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In 2014, Indira has a degenerative muskulo-skeletal diagnosis. She sees the
orthopaedic, podiatry and physiotherapy teams in 3 different places and times and
has to make yet another appointment if she needs any diagnostic tests. In 2019, she
is seen in an integrated common assessment & treatment service (ICATS) where she
can see all the specialists and get her tests on the same day in the same place.
In the same way, our organisation will look very different in 5 years’ time. In 2019, our
patient and staff feedback will rank us as one of the top Trusts in the country in
recommending us to their families and friends. We will have expanded our service
provision into neighbouring counties and will be competing in some of our planned
care services with private sector companies.
In 2019, we will have delivered our long term financial model, notably our cost
improvement programme, while continuing to transform our service models and
improve quality as the patient stories above demonstrate. Our estate and IM&T
strategies will have been delivered as an integral part of delivering the new service
models.
Business development strategy
The other important component of our strategy has been our approach to business
development. Section 4 outlines our approach. Our focus is first and foremost to
maximise the health and well-being of, and be the community services provider of
choice for, the population of Derbyshire. This is particularly for those services
supporting the frail elderly and children, which are best provided as part of an
integrated pathway and approach, especially where close working with primary care
teams is paramount.
However, the Trust has been successful in providing services elsewhere across the
East Midlands, notably elective care and community dental services in
Leicestershire. A key business development priority, informed by our investment
policy, is an aspiration to provide sub-acute episodic specialist community services
such as planned care in any of those areas surrounding those where we already
provide care.
In addition, we are aware that there may be opportunities to expand further beyond
our current income base through merger or acquisitions, given the rapidly changing
market place and financial environment. Again, our commitment remains to being the
best provider of services to our existing communities first and foremost. But where
there is an opportunity to expand, we would now consider providing a pathway of
care, comprising elective, rehabilitative and long term care services, outside
Derbyshire and adjacent to where we currently provide services where this fitted our
investment policy.
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Where we have worked outside Derbyshire thus far, it has brought significant patient
and quality gains to local services in drawing on best practice across services. It is
also one part of our risk mitigation strategy against losing other areas of business
and it has been of considerable reputational benefit for the organisation.
Equally, we have taken some tough decisions about those services which are not
core business or which are uneconomic to run – thus we no longer provide patient
transport and stroke rehabilitation services, as we believed others were better able to
provide these services.
Partnership development
Over the lifetime of the plan, we will continue to develop our approach to partnership
development which more closely reflects the best way of delivering increasingly
integrated service models and gathering feedback about our services. There may
well be different partnering and supply chain models for differing services dependent
on the specific patient requirements, provider capabilities and aspirations. We
anticipate working more closely with the third and private sectors in particular and our
membership strategy also sets out how we will work with our members and the wider
community.
Thus we already have strategic partnerships in place and we will seek to build on
these where possible, also acting as a lead or supporting provider in a pathway
depending on the service and the capability, capacity and aspirations of our own
organisation and others we are working with.
1.5
Rationale for NHS foundation Trust status
The Trust’s rationale for becoming a foundation Trust (FT) is summarised here and
set out in more detail in section 4. Effectively the FT rigour and processes have been
applied over DCHS’ life time as an Autonomous Provider Organisation (APO) and
now as a Trust. We have always been clear that FT status was a means to an end
rather than an end in its own right. In other words, we have always believed that FT
status was the best way of achieving a real focus on quality care for our patients,
supporting our staff effectively and developing the organisation as a sustainable
business in the longer term.
DCHS wishes to become a community foundation Trust so that we can:
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Increase our accountability to the public we serve;
Develop stronger links with local communities through our newly established
membership scheme;
Have greater financial freedom so we can be more innovative and improve the
services we provide more quickly;
Form new partnerships with other service providers to improve our patients’
experience of our services;
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Continue to develop the Trust as a more commercial organisation, able to
operate effectively in a more competitive market.
Thus, we have developed our membership strategy to enable us to attract and work
successfully with our members as an invaluable asset in giving feedback on and then
shaping our service portfolio. Our aim is to support our governors in such a way that
they can genuinely hold the board to account and feel confident and capable in
shaping the Trust’s strategy and the whole way it undertakes its business consistent
with the DCHS way.
Our financial planning and reporting is also continuing to be developed so that we
maximise the financial freedoms of FT status, especially around the management of
our service lines, our cash, investment strategy and use of all assets. This in turn is
supporting the strengthening of our business development processes as we ensure
the Trust can operate in an environment of greater choice, regulation and
competition.
1.6
Service Development Plans
Section 5 outlines the key plans the Trust has for developing its services, outlining
the key assumptions and planning drivers as well as the project management
assurance framework for overseeing a major change programme. While setting out
an ambitious programme of change, these plans build on the organisation’s service
and corporate strengths, underpinned by a real track record of delivery of change,
improved quality and value. These plans reflect the market and competitor analysis
and the huge amount of staff engagement undertaken as part of the IBP’s
development and revision.
There is specific reference to the changes we have planned for our support services
partly because we see these as equally important as the clinical services we offer
and partly because of the major change agenda which is required if they are to
genuinely support clinical services in the transformation needed over the life time of
the plan.
What has emerged is that there are some clear principles which must underpin all
our services. So, all our developments emphasise the following key service principles
which derive from the key issues arising from the PESTLE and
SWOT:
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Providing a single point of access & clinical navigation– to ensure that it is
quicker and easier to use and access our services for both referrers and
service users and to ensure a rapid referral to the most appropriate service for
the service user;
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Provide care as close to home as appropriate – by providing care as close to
home as appropriate, shifting the balance of care to support people more in
their own communities;
Creating integrated service and pathway provision – by reducing hand-offs
between organisations and ensuring joined up care and giving more control to
patients;
Ensuring all services promote health and independence – by treating service
users in a holistic way that helps prevent illness and promotes good health,
along with reducing health inequalities, ensuring that ‘Every Contact Counts’;
Ensuring care is efficient and effective – all processes that underpin and
support the delivery of care are delivered through an integrated model of
provision based on recognised best practice and evidence based clinical
interventions and through a process which has addressed the risks to the
organisation and the impact on quality.
The service development plans section focuses on a number of key programmes of
service change, driven by the planning analysis described earlier, namely:
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Adults’ services – with a particular focus on Frail elderly;
Older People’s Mental Health
Learning disability services;
Children’s services;
Specialist services;
Planned care and outpatients services;
Support services.
The section outlines the case for change, the details of the proposed changes and
the resource impact, primarily around workforce, estate and information management
& technology / more productive working. It also outlines new project management
office (PMO) arrangements for overseeing the quality and delivery of our change
programmes building on our track record of both increasing efficiency and quality.
1.7
Quality
While quality is embedded throughout the IBP, the Quality Strategy was felt to be
such a critically important document that it has been incorporated as a chapter in its
own right within the IBP.
The strategy supports the delivery of high quality and equitable services that meet
people’s needs. It provides a framework to ensure that quality services are delivered
in response to the specific requirements of our patients and public, our
commissioners and our regulators. It defines quality as:
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The delivery of services which are focused upon patient safety and reducing
risk which may cause harm;
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The delivery of services which are effective in the context of clinical outcomes
and patient related outcomes;
The delivery of services which are considered by our patients, service users,
their carers and families as being a positive or good patient experience.
Section 6 sets out our approach to continuous quality service improvement
incorporating what our priorities are, how they will be delivered and how we will know
when they have been delivered. This approach is set in the national and local
context, setting out clear priorities in the short and longer term, within a new quality
governance framework and set of accountabilities and responsibilities.
1.8
Financial plans
The key financial objective over the life of the Integrated Business Plan is to support
the delivery of the service strategies within a sustainable financial plan. DCHS does
not underestimate the financial challenges it will face in the current and future
economic environment. However, the strong financial management of the past, and
the development of financial systems and processes going forward will place the
Trust in a strong position to thrive in the future.
The financial plans, based upon a set of realistic assumptions, demonstrate that the
Trust will deliver a Continuity of Services rating of 4 in all years. . The Trust will
deliver improving financial results underpinned by a strengthening balance sheet due
to increasing cash reserves. The surplus will reach £9.0 million by 2019/20, and the
cash position will be £45.8 million. Detailed implementation plans have been
developed and will be performance managed through the Programme Management
Office (PMO). A key part of the PMO role is to ensure that all schemes are
appropriately Quality Impact Assessed, and signed off by the Medical Director and
Chief Nurse.
DCHS will need to deliver challenging cost improvements in a difficult financial
environment. However, plans are in development which will enable us to provide
innovative service models which our commissioners and customers demand and
which enable us to improve the quality of the service we provide, at less cost.
The Board has recognised that systems need to be developed to enable the Board,
and the finance function, to operate effectively in a foundation Trust regime. Control
systems have been strengthened, Board reporting is being improved, and the
organisation is developing its competence and understanding of working in the
foundation trust financial environment.
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1.9
Key Risks
From the external assessment, SWOT analysis and financial planning, DCHS has
defined a number of business risks that the organisation faces and mitigating plans
against these risks.
DCHS has identified a number of high level strategic risks from the overall analysis
within this plan. These strategic risks are:
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Risk to quality – failure to consistently deliver a safe, effective service to
patients and clients, with associated risks of harm to patients, regulatory,
reputational and financial consequences
Risk posed by people – failure to maintain a high performance work
environment that positively supports and engages people to fulfil their
potential, with the right people, with the right skills in the right places.
Risk posed by business finance – failure to deliver financial plans and maintain
a financially viable and sustainable organisation.
Risk posed by business strategy – failure to understand and address
competitive pressures in changing environment, resulting in loss of business,
or inability to deliver service changes required due to failure in identifying and
managing policy, political and stakeholder context.
Business infrastructure – failure to manage key areas of enabling
infrastructure change to support service strategies
Risks posed by governance – failure to develop and maintain effective
governance systems that underpin long term success and support the
control/assurance systems developed to mitigate against key strategic risks.
DCHS has considered the impact of these risks in constructing a downside case. The
downside case assumes deterioration in the Trust’s financial health and by 2019/20 a
shows a deficit of £35.2 million, and a cash position in deficit by £35.2million. In this
case, the Trust is able to implement mitigating actions which result in the continuity of
service rating being maintained at a 4 for each year of the model. This modelling and
mitigation provides assurance to the Board that DCHS can demonstrate its continued
financial viability under a downside case.
1.10 People & organisational effectiveness
Employee engagement will be crucial as we implement new service models,
transform our workforce and introduce new technology and agile working to increase
productivity. The Trust is very proud of the of its track record successful delivery of
change and the year on year improvement in our staff survey results positioning
DCHS as the top specialist community Trust nationally as a place to receive
treatment and to work.
Section 9 outlines the main workforce characteristics of the Trust, in particular that it
is primarily female, with 63% of positions being part-time, it has 52% of employees in
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the age range of 46 years and over, low turnover at 9.74% and good attendance at
around 95.99% (during 2013/14).
A workforce transformation programme has been developed as part of the IBP to
support the service developments through a range of measures described in detail in
Section 9. This sets out the workforce and employment transition to deliver integrated
services working with health and social care partners.
DCHS has developed ‘Quality People, The DCHS Way’ a new five year People
Strategy having completed the 2012 -2017 People Strategy two years ahead of plan.
This new strategy sets out how we will further embed the DCHS Way through three
core themes Attract, Grow and Retain, and Engage underpinned by key focus
areas and three strategic priorities – the key ingredients to ensuring DCHS is a high
performing Foundation Trust and truly a great place to work. The strategy supports
the delivery of the IBP and our five year workforce plan.
We are commencing a quality and continuous improvement programme that will
require sustained excellence in organisational development and service
improvement. This all links to and emphasises the critical importance of effective
leadership in delivering an IBP of this magnitude. Our plan outlines our approach to
leadership development at all levels of the organisation, and how important the
health and wellbeing, the recognition and engagement of our staff teams are in
delivering our vision and values for our patients and staff.
1.11 Governance arrangements
The Trust consulted on the proposed governance arrangements for the Council of
Governors and the responses informed the final governance arrangements that have
been incorporated into the Trust’s constitution. The Shadow Council of Governors is
now in operation, and is starting to make a valuable contribution to the governance of
the Trust. The Membership Strategy sets out how we ensure our governors have an
active role within the organisation and are able to make a positive contribution to
improving patient care.
The Trust has established a number of committees with delegated authority from the
Board of Directors. These Committees are chaired by Non-Executive Directors and
have a vital role in ensuring the Board receives assurance that the organisation’s
strategic objectives are being delivered.
The Board has the ultimate responsibility for risk management and the review and
approval of high risk treatment options. The Trust’s risk management framework
encompasses a Risk Management Policy which describes DCHS’ approach to risk
management including the processes, roles and responsibilities which underpin it.
The Chief Executive of DCHS has overall responsibility for DCHS’ risk management
processes.
Page | 16
The Trust has a Board Assurance Framework that reviews the strategic risks to
achieving strategic objectives, and a risk register that ensures risks are captured
“bottom up” from patient level to “top down” from the Board. These risks are captured
and risk assessed, with mitigation plans put in place to treat the risk.
We are committed to learning from incidents, Serious Case Reviews, Coroners
cases, disciplinary hearings and any claims. Systematic investigations take place
using agreed methodologies and, for serious incidents, a Rapid Response team is
formed.
The Trust has developed performance and financial reporting to ensure it focuses on
key organisational risks, and that it is forward looking so that issues can be managed
proactively. The performance framework has been updated to provide a strategic
framework to enable overall coordination of all performance management activities
across the Trust and ensure alignment with the Trust’s business strategies and
strategic objectives and underpins the Trust’s Assurance Framework
KPMG are the Trust’s external auditors and 360 Assurance are the internal auditors
and providers of Counter Fraud services.
1.12 Summary
In summary, this IBP allows us to take a long term view of the services we provide
and really challenge what they need to look like in 5 years’ time to provide quality
services, provided by quality people as part of a quality business. Whilst ambitious to
reflect the changing requirements of our patients, our plans build on strong analysis
of our internal and external environment and our track record of delivering change
alongside enhanced quality and value.
Key to the development of this document has been the on-going engagement of our
staff whose expertise and local knowledge has been the inspiration behind much of
its content. It is our staff who will make a reality of the vision and values and their
commitment has been essential.
Our thoughts have also been shaped by the people who use our services, their
carers and our partnering organisations, including the clinical commissioning groups
and our other health, social care and voluntary sector partners.
It is only by working together that we will deliver this radical plan and, in so doing,
make a real difference to the lives of the people for whom we care and with whom we
work.
Page | 17
2
Trust Profile
Purpose of this section:

Outline who DCHS is and the organisation’s journey so far;

Introduce the DCHS Way;

Provide an overview of the organisation’s performance;
KEY FACTS
Turnover
£156,700,000
Employees
Whole Time Equivalent - 3,177
Headcount - 4,098
Total number of patient
contacts per day
Over 4,000
Patient population served
Approximately 1,000,000 across Derbyshire including Derby City.
However DCHS delivers services across other areas of the East
Midlands, with an overall population of 4,500,000.
Premises
Services are delivered from 133 premises including 13 community
hospitals and 28 health centres
Bed complement
292 (at April 2014)
CQC registration status
Unconditional and full registration with the Care Quality Commission
In an average day:




150 people will be seen in DCHS minor injury units
300 people will be cared for in our community hospital beds
More than 1,400 patients will be supported by our community nursing teams
387 children aged 0-5 will be seen by our health visitors
Table 1 - DCHS Key Facts
Page | 18
2.1
Overview
DCHS is a large specialist community services provider, with a significant portfolio of
community based services across Derbyshire and surrounding counties.
DCHS was formed in 2006 as the provider arm of Derbyshire County Primary Care
Trust (PCT). DCHS has operated as a fully Autonomous Provider Organisation
(APO) from 2006 operating with its own Board. DCHS was established as an NHS
Trust on 1 April 2011 as the preliminary step to submitting a formal application to
become a Community Foundation Trust (CFT).
Since its inception, DCHS has worked towards Foundation Trust / Monitor compliant
systems and processes. We have always believed this approach to be in the best
interests of our patients, staff and commissioners. In March 2009, DCHS submitted
an expression of interest in becoming a community foundation Trust stating that:
‘As a Community Foundation Trust, Derbyshire Community Health Services will
energetically explore new and better ways of delivering community-based care,
raising standards of care for those it serves and advancing regional and national
community services practice. We believe we are in a strong position to take on the
challenges involved and are enthusiastic and committed delivering the benefits the
opportunity offers to our communities, our staff and our commissioners.’
Following significant staff and stakeholder consultation during 2009 and 2010 it was
concluded that the right choice for DCHS would be to pursue an application to
become a Community Foundation Trust. This was supported at the time by NHS
Derbyshire County and NHS East Midlands, as well as primary care teams and
Derbyshire County Council and has subsequently been supported by the four clinical
commissioning groups established in Derbyshire from 2013. DCHS’s initial
application for authorisation as a Community Foundation Trust received Secretary of
State approval in 2012, Monitor concluding its review in 2013. Following its review,
Monitor stated DCHS was well led, but despite confirming approval for our
governance processes and financial viability, Monitor required us to make
improvements on four service issues highlighted by the Care Quality Commission
(CQC) in 2013; these have subsequently been reviewed as fully compliant by the
CQC. In May 2014 the CQC reported on a further inspection of DCHS utilising the
new inspection regime overseen by Sir Mike Richards, Chief Inspector of Hospitals.
As the trust was inspected in the pilot phase of the new regime a rating was not
given.
This CQC review has demonstrated that DCHS:
 Can demonstrate high quality services
 Hit its financial targets
Page | 19



Has strong health and social care community links
Has a strong commitment to partnership and integrated working
Has a positive culture and committed workforce
At the time of writing, DCHS expects to restart the Monitor application process in July
2014 with a view to becoming a Foundation Trust by the end of 2014.
2.2
DCHS Services
DCHS is a large and complex community services provider, providing community
based services across Derbyshire and beyond. It has a strong track record of
delivery, including the temporary hosting, between 2011 and 2014, of a significant
portfolio of services in Leicestershire including outpatient and day case surgery, the
provision of community dental services in Leicestershire, and the delivery of services
into other surrounding counties such as Staffordshire and Nottinghamshire. DCHS
currently delivers its services across three main business units, these being:



Health, Wellbeing & Inclusion
Planned Care (Outpatient and Day case)
Integrated Community Based Services
Table 2 demonstrates our range of services:
Health Wellbeing and Inclusion
Service Line
Health Visiting
Children's
School Nursing
Sunshine Nursery
SLT - Adults
S&LT
SLT - Children's
Derbyshire Dental
Dental
Leicestershire Dental
HP - Children's and Young People
HP - Integrated Healthy Lifestyles
Health Promotion
HP - Health Education for Adult
Health Psychology
Chlamydia Screening
C&SH
Contraception and Sexual Health
HP - Sexual Health
Head of Service
Planned Care
Head of Service
Therapy Out-patients
Podiatry
Equipment
Derbyshire Elective Services
Service Line
Outpatient Occupational Therapy
Outpatient Physiotherapy
Community Podiatry
Podiatric Surgery
Orthotics
Wheelchair Services
DTC - Daycase Surgery
DTC-Outpatients
Integrated Community Services
Service Line
Clay Cross and Bolsover Hospitals
Integrated Community Teams NED
ICS North East
Disability Services Head Injury
Stroke Services
Integrated Community Teams CFD
ICS Chesterfield
Walton Hospital
Respiratory Team
Buxton, Newholme and Whitworth Hospitals
ICS High Peak and Dales
Integrated Community Teams HPD
ICS South Derbyshire
St. Oswalds Hospital
Integrated Community Teams SD
Heart Failure Team
ICS Amber Valley
Integrated Community Teams AV
Ripley, Babington and Heanor Hospitals
Ilkeston Hospital
ICS Erewash
Integrated Community Teams ERE
Continence Nursing
Learning Disabilities
LD - Inpatients
LD - Community Teams
LD - Short Breaks
Older People's Mental Health LD -Short Breaks
Evening Nursing Service
Evening Nursing Service - DHU
Head of Service
Table 2 - DCHS Service Portfolio
2.3
The DCHS ‘Way’
In order to take the organisation forward and to underpin our brand, vision and
strategy we developed the DCHS Way to remind staff, partners and service users of
Page | 20
our key principles and priorities. The DCHS Way underpins all of DCHS systems and
processes to ensure a consistent drive in taking the organisation forward both as a
Foundation Trust but also as a high quality sustainable provider of health care. The
DCHS Way is structured around our organisational objectives and is built around the
concept of Quality Service, Quality People and Quality Business.
Figure 2-1 - The DCHS Way Objectives
For example the appraisal and performance review process is structured around the
three DCHS Way themes of Quality Service, Quality People and Quality Business
and work objectives are also aligned along these. The DCHS committee structure
has also been structured with formal sub-committees of the Board established for
each of the DCHS way themes [See section 10.1 for further details].
2.4
Main commissioners
Given the wide geographical scope across numerous different commissioning
organisations, DCHS currently contracts the bulk of its services on a single
multilateral contract, with North Derbyshire Clinical Commissioning Group being the
lead commissioner on behalf of the other statutory commissioners in Derbyshire.
DCHS has worked closely with CCGs as they have emerged in the last two years
and have built solid foundations for taking forward service redesign to meet the
potential for core service delivery with local flexibility. There are 4 CCGs in
Derbyshire:
 NHS North Derbyshire CCG
 NHS Erewash CCG
 NHS Southern Derbyshire CCG
 NHS Hardwick Health CCG
In addition, DCHS borders six other counties and has adjoining or very close
boundaries with a further 16 CCGs.
Derbyshire County Council also commissions a number of DCHS services, which
include health promotion and learning disability services.
Page | 21
The Trust has a multi-lateral contract with commissioners. The material
commissioners within the contract (defined as income of 5% or more) are:
 North Derbyshire CCG
 Hardwick CCG
 South Derbyshire CCG
 Erewash CCG
 NHS England
 Derbyshire County Council
The mandatory services currently included within the contract are:
 Community Nursing (in hours and Out of Hours services)
 Health Visiting Services
 OPMH Inpatient Service
 Learning Disabilities Services
 Intermediate Care Services (including inpatient and community services)
 Continence Nursing Services
 Day services / specialist rehabilitation units
 Head Injury Services
 Health Promotion Services
 Specialist Nursing Services (Heart Failure, Diabetic Liaison, Parkinson’s,
Tissue Viability, Neurotherapy)
 Wheelchairs services
Under the grandfathering arrangements set out in guidance, these mandatory
services will automatically become Commissioner Requested Services, and will be
included on the Trust’s CRS schedule.
Within Derbyshire, the Clinical Commissioning Groups are currently developing their
five year plans. As part of this work, discussions are underway across the North and
South Units of Planning as to how services will look in the future. Following this work,
commissioners intend to engage with all providers to determine which services need
to be designated as Commissioner Requested Services.
Work around reviewing Commissioner Requested Services will be taken forward
through the Contract Management Group, with a recommendation taken to the
Contract Management Board for decision. The Contract Management Group is where
operational issues are discussed between the Trust and commissioners. It is chaired
by North Derbyshire CCG as our lead commissioner, and has attendees from our
other commissioners. Contract Management Board is where strategic issues are
discussed and is chaired by the Chief Officer of North Derbyshire CCG.
The tables below outline the detail of our main contracts for the financial year
2014/15
Page | 22
NHS
NHS NORTH SOUTHERN
DERBYSHIRE DERBYSHIRE
CCG
CCG
£'000
£'000
NHS
HARDWICK
CCG
NHS
EREWASH
CCG
£'000
£'000
Derbyshire
National
County
Commissioning
Council (DCC)
Board
£'000
£'000
Other
Commissioners Total 2014/15
£'000
£'000
Multilateral Contract
Na tiona l PbR Ta ri ff
997
4,027
145
3,162
-
-
1,052
9,384
Loca l Cos t a nd Vol ume Ta ri ff
5,038
6,763
1,136
1,664
-
-
486
15,086
Lea rni ng Di s a bi l i ty Servi ces
8,204
6,177
-
1,916
-
-
-
110
Hea l th & Wel l bei ng
-
-
-
-
5,803
-
460
Chi l dren's Nurs i ng Servi ces
-
-
-
1,789
9,846
-
11,657
21
6,264
Core Communi ty Tea ms
9,841
6,686
4,154
3,280
-
-
-
23,961
Wra p Around Communi ty Servi ces
4,702
3,214
1,995
735
-
-
-
10,645
19,159
8,719
4,688
3,417
-
-
590
36,573
Da y Servi ces
3,154
608
766
-
-
-
12
4,540
Other
1,839
2,090
665
741
647
1,355
262
177
1,154
1,010 -
162
1,244
828
51,643
Derbys hi re Dental
Lei ces ters hi re Dental
Communi ty Beds
-
-
5,378
-
-
-
2,441
306
-
-
-
383
333
191
-
35,322
15,948
13,815
7,826
9,846
-
-
-
-
-
-
5879
5879
-
-
-
-
-
-
3234
3234
Hea l th Promotion Contra cts (DCC)*
-
-
-
-
-
587
Total Other Contracts
-
-
-
-
-
51,643
35,322
15,948
13,815
7,826
Pa s s Through Cos ts
Contra ct Reba s i ng
-
CQUIN
Total Multilateral Contract
42
68
3,046
2,779
137,178
Other Contracts
Grand Total
-
587
587
9,113
9,700
10,433
11,892
146,878
Table 3 - DCHS Main Commissioners3
2.5
Workforce and Organisational Structure
To support the breadth and range of services provided, DCHS employs more than
4,000 talented and dedicated staff across a wide range of professional groups. The
workforce profile as at April 2014is set out below:
Staff Group
FTE
Total Headcount
Allied Health Professionals
396.56
487
Health Care Scientists4
7.74
12
Medical & Dental
45.42
83
NHS Infrastructure Support5
1085.71
1445
Other Scientific, Therapeutic and Technical Staff
117.82
171
3 Please
note table 3 represents the multi-lateral contract and does not include other sources of
income from other contracts.
4 These are Phlebotomy staff
5 This includes Senior Management, Administration and Estates
Page | 23
Registered Nursing, Midwifery and Health visiting
staff
899.87
1091
Support to clinical staff6
623.89
809
Grand Total
3177.00
4098
Table 4 - Workforce Profile
DCHS puts significant emphasis and focus upon its workforce, which is reflected
throughout the organisational vision, ambitions and objectives, and is a core
component of the overall strategy. This emphasis is demonstrated by DCHS having
a low turnover rate of 9.74% and an overall attendance rate of 95.99% (2013/14).
The broad structure of DCHS can be seen in the directorate/divisional diagram
below:
DCHS
Key:
Operational
Services
Chief
Executive’s
Office
Corporate
Directorates
Professional Clinical
Directorates
Service Delivery
Head of
Emergency
Planning
Assistant Director
North Division
Integrated Community
Based Services
People &
Organisational
Effectiveness
Finance
Assistant Director
South Division
Integrated
Community Based
Health,
Wellbeing &
Inclusion
Strategy
Quality &
Patient
Experience
Planned Care &
Outpatients
Services
(Deputy Director)
Clinical Director
Integrated
Community Based
Services
Figure 2-2 - DCHS Organisational Structure
6
This includes all Clinical support such as HCA’s Care Support workers and AHP support workforce
Page | 24
Medical
2.6
Historical Performance
DCHS has an excellent and strong demonstrable history of delivering against
national and local outcomes and targets, along with a strong history of delivering
positive financial performance. Along with this DCHS also has an excellent track
record of achievements across the organisation, recent achievements include:
Quality Service




Achieved a score of more than 99% from a team of patient and staff
assessors for levels of cleanliness in our hospitals.
Achieved a score of over 90% by a team of patients and staff assessors for
our standard of food.
Continue to have zero cases of MRSA bacteraemia within our community
hospital beds.
DCHS is within the top 25% of trusts for Patient Safety Incident reporting
which indicates ‘a better and more effective safety culture’
Quality People




Finalist in 2012 CIPD People Management Awards for Employee
Engagement
Finalist in 2013 CIPD People Management Awards for Organisational
Learning
Year on year improvements on the NHS Staff Survey, with 2013 seeing our
highest response rate to date and being ranked 1st for our FFT results
against all other Community Trusts
Winner of 2013 RSPH Health and Wellbeing Award, being awarded the
highest level of 3 years
Quality Business

Our Investors in Excellence standard has been re-certified for a second
term and we remain the only NHS Trust to hold it


ISO 9001:2008 Quality Management System has just been recertified
ISO 14001:2004 Environmental Management has just been recertified
The table below outlines the historical performance for DCHS against key national
and local outcomes:
Page | 25
Key Performance Indicator
Threshold
2010/11
2011/12
2012/13
2013/14
Quality Service
MIU 4 Hour Wait
6 Week Wait for Diagnostics
Delayed Transfer of Care
95%
??
99.70%
99.85
99.87%
100%
n/a
100%
99.99%
99.74%
13.20%
8.10%
8.60%
 trend 18.20%
Referral To Treatment Targets
Achieved
Achieved
Achieved
Failed RTT
waits
greater than
52 weeks.
Achieved all
other
targets
CQC Failures of Registration
0
0
0
0
0
MRSA Bacteraemia incidences
0
0
0
0
0
Clostridium Difficile incidences
Single Sex Accommodation
Breaches
12
24
12
12
9
0
??
0
0
0
95.20%
95.80%
95.60%
96%
n/a
n/a
1.60%
3%
79.00%
88%*
100%
97%
3
3
3
3
95%
93.10%
99%
99%
98%
95%
98.10%
97%
97%
97%
100%
104%
90%
100%
100%
Quality People
Staff Attendance Rate
Agency & Bank Spend as a % of
Turnover
Essential Learning
97%
95%
Quality Business
Continuity of Services Rating
Better Payment Practice Code - by
value (%)
Better Payment Practice Code - by
volume (%)
CIP Achieved
3
Table 5 - DCHS Historical Performance
DCHS also has a strong historical financial track record and has consistently met its
duty to break even, to fully recover the costs of delivering its services, to manage
cash resource within the Capital Resource Limit and to deliver a 3.5% return on its
assets.
In 2013-14 DCHS delivered its financial plan including a net surplus of £2,892,000,
achievement of its Cost Improvement Programme of £8,400,000 on a recurrent basis
along with delivery of planned income and expenditure ratios. Table 6 - 2011-12
Financial Performance below outlines the financial DCHS performance for 2013-14
Page | 26
2013/14 Plan
Audited
Accounts
£’000’s
£’000’s
Income
Clinical
Non-clinical Income
Total Income
168,156
9,111
177,267
171,605
11,596
183,201
Expenditure
Operating Expenses
Non-operating Expenses
Total Expenditure
170,533
4,010
174,543
176,023
4,286
180,309
Operating Profit(Loss) - EBITDA
Net Surplus/(Deficit)
6,734
2,724
7,178
2,892
Final Net Surplus
,2,724
2,892
Table 6 - 2011-12 Financial Performance
Key points of this section:

DCHS is a highly performing organisation which delivers a number of
specialist community services across Derbyshire and beyond;

DCHS has operated as an autonomous organisation and developed its
organisational capacity since 2009;

DCHS has a strong track record of achieving financial surplus and statutory
targets.
Page | 27
3
The Environment in Which DCHS Operates
Purpose of this section:

Understand the work that DCHS has undertaken to analyse the key factors
and drivers which underpin the service development strategy in section 5 by:
o Outlining the position of DCHS in the wider health and social care
community in Derbyshire and beyond;
o Developing an understanding of the impact on DCHS from the
demographic analysis;
o Understanding the competitors to DCHS and the market in which
DCHS operates;
o Outline the actions which DCHS has in place to address this analysis.
Population
Total area
Population density
Population growth forecast
(over 20 year period)
Life expectancy
3.1
Key Facts7
1,000,000 (approx.) – including Derby City.
1,014 mi2
Higher than regional average population density of 990
people per square mile.
ONS projections for the Derbyshire population suggest a
13% population growth across all ages within 20 years
and a 12% projected increase for the 65+ age range
within 5 years, rising to 52% increase in 20 years. , The
corresponding increase in the 90+ age range is over
145% in 20 years
Life expectancy in line with national average of 78 for
males and 83 for females. However, life expectancy is
7.7 years lower for men and 5.6 years lower for women in
the most deprived areas of Derbyshire than in the least
deprived areas.
The Health & Social Care Economy in Which DCHS Operates
DCHS is the specialist community services provider within Derbyshire, providing a
wide range of community-based services across the county, but also providing a
range of commissioned services in adjoining counties. Given Derbyshire’s unique
Key Facts data sourced from: Public Health England Derbyshire Health Profile 2013 /Market & Competitor Analysis January
2014
Page | 28
geographic position it is well placed to deliver services in any of the surrounding
counties.
Figure 3-1 below highlights the position of DCHS within the Midlands and its position
relative to the surrounding counties. This position offers opportunities for providing
services in surrounding counties. [See section Error! Reference source not found.
for further information on our approach to business development].
1
7
6
2
5
1.
2.
3.
4.
5.
6.
7.
South Yorkshire
Nottinghamshire
Leicestershire
Warwickshire
Staffordshire
Cheshire
Greater Manchester
3
4
Figure 3-1 - DCHS Geographic Position
The local health economy consists of a wide range of different providers from the
public, private and voluntary sector and providers from neighbouring counties. These
include:




Acute Foundation Trusts
o Chesterfield Royal Hospital Foundation Trust
o Royal Derby Foundation Trust
o Stepping Hill Hospital – Greater Manchester
o Sheffield Teaching Hospitals Foundation Trust– South Yorkshire
o Burton Hospitals Foundation Trust – Staffordshire
Acute NHS Trusts
o Nottingham University Hospitals – Nottinghamshire
o University Hospitals of Leicester – Leicestershire
Community Providers
o Bridgewater Community Healthcare NHS Trust – responsible for the
provision of a wide range of community services available to about
900,000 people in the Greater Manchester area
o Staffordshire and Stoke-on-Trent Partnership NHS Trust – Staffordshire
Mental Health Trusts
o Derbyshire Healthcare Foundation Trust
o Nottinghamshire Healthcare NHS Trust
Page | 29



3.2
o Leicester Partnership Trust - Leicestershire
Independent Sector Treatment Centre, Barlborough – operated by CareUK
124 GP Practices within Derbyshire & Derby City
Out of Hours Provider – Derbyshire Health United
Demographic Analysis and Health Needs
DCHS has undertaken a significant demographic analysis reviewing a wide range of
factors and projections89. The demographic data for Derbyshire outlines a County
which has a diverse and polarised health profile, along with having higher than
national average population growth and incidence of long term conditions. The
following analysis picks out the key points that arise from this.
Over the next 20 years, in terms of age profile and population growth, Derbyshire is
expected to see an overall population increase of 13% , the 65+ age profile will
increase by 52%, whereas the under 65 age group will see modest growth.
In particular, over the next 20 years, the age group from 70-79 will see an increase of
45%, the 80-89 age group will see an increase of 79% and the 90+ age group will
see the largest increase of 145%.
Long term conditions prevalence rates are in the main higher within Derbyshire than
the national average which, when linked with the ageing population, will be a key
driver for DCHS services.
The North East area of Derbyshire is facing significant levels of deprivation and
associated health related impacts.
In relation to health needs:
 The following areas are better than the England average:
o Levels of alcohol-specific hospital stays among those under 18
o Breast feeding initiation
o Smoking in level of teenage pregnancy
o The rate of sexually transmitted infections
 Deprivation is lower than average, however about 24,000 children live in
poverty.
 Life expectancy is 7.7 years lower for men and 5.6 years lower for women in
the most deprived areas of Derbyshire than in the least deprived areas.
 About 20% of Year 6 children are classified as obese.
 The estimated level of adult obesity is worse than the England average.
DCHS Market and Competitor Analysis – January 2014 Version
For the purposes of this document the main conclusions are taken from the referenced detailed
analysis.
8
9
Page | 30

Health and wellbeing priorities include:
o Inequalities in avoidable mortality
o Early years health and literacy
o Alcohol, obesity and inactivity
o Community management of long term conditions
o Access to psychological therapies
o Health and independence in old age.
Further work on Derbyshire demographics and implications for the whole Derbyshire
health economy is currently being undertaken by Finnamore. Finnamore have been
contracted by the CCGs to do some county-wide work on the health economy and
some work with North Derbyshire Unit of Planning on their strategy and plans (see
section 3.3 General Changes in the Local Health Economy).
The key points from the above demographic analysis are:
 Derbyshire will see significant increase in the over 65 year old population;
 The biggest increases in age profile are expected across the 70-79 and 90+
ager groups;
 Derbyshire has levels of deprivation in some areas significantly higher than
the national average;
 Derbyshire has significant health inequalities.
Analysis suggests that demand for DCHS services will particularly increase in those
services across the frail elderly pathway, and also for children’s services with
families needing increased support. These demographic factors will be addressed
as part of the service development plans outlined in section 5.
3.3
General Changes in the Local Health Economy
The last few years have been difficult for the NHS; the Derbyshire health economy
has not escaped this. We now operate in an environment of tightening financial
constraints, increasing demand, a growing focus on integration, increasing
transparency and openness, increasing focus on safety and technology and on
managing the frail elderly more effectively.
As shown in the next section, the effect of all these influences appears to be a
‘segmentation’ of the market into health-commissioned services, where more
partnership working is being encouraged, and council-commissioned services, where
competitive tendering is being pursued.
Political change is never far away and, with a general election approaching in 2015,
this is perhaps even more of a consideration now. However, despite many
differences in the views of the different political parties, there are a number of key
areas they appear to have some agreement on. These include the need for more
Page | 31
integration, openness regarding quality, tighter controls on finance and the need for
more focus on care of older people and long term conditions. We therefore need to
be able to respond positively in these areas, but also be flexible enough to respond
to the changes different political parties could bring to the Health and Social Care
system.
The Finnamore work for North Derbyshire Unit of Planning (see 3.5 Commissioning
Landscape) highlights the key drivers for change in the local health economy (Figure
3-2).
Figure 3-2 – Key drivers of change
Changing Needs:
 The NHS was set up to help sick people get well, often in a hospital setting
(episodic care)
 The service is now struggling to meet the changing nature of demand for
ongoing complex care
System Capabilities – Un-resilient services:
 Skills shortages
 Fragmented service provision organised around facilities
 Progress in moving away from bed based care has left some small, isolated
wards
 Some poor quality estate
Financial Pressures – Unprecedented financial challenge:
Page | 32



NHS funding flat in real terms but demand growing by c.5% pa.
Local Government -28%
Health and adult social care challenge is £125m-£150m
Local Care Needs – Increasingly elderly population:
 Ageing population - significantly higher than national average
 High prevalence of long term conditions (Coronary Heart Disease, Diabetes
and Hypertension)
Section 3.5 Commissioning Landscape highlights how the CCGs and Units of
Planning are proposing these challenges are met.
3.4
Provider Landscape
DCHS’ Commercial Strategy highlights that alongside our primary focus of delivering
services for people in Derbyshire, we will also look at opportunities as they arise
which are both on our borders and are reflected within our current core service
portfolio. Using these parameters, DCHS has undertaken a significant competitor
and partner analysis, which is refreshed annually so as to take account of changes
within the sector and to capture the changes to the market. This analysis takes into
account the services delivered, their current turnover, staff, distance away from
DCHS services, strategic intent and the threat that they pose to DCHS. In addition
monthly Business Development Reports are drafted for Quality Business Committee
which includes the latest market, environment and competitor intelligence.
In defining key competitors and partners a market was defined as an area 20 miles10
from 3 strategic points within Derbyshire in which to undertake research on
competitors. These points are in the North East, the High Peak and south of the
county. A large number of organisations have been identified across Derbyshire and
surrounding counties, across six different sectors.
Appendix G outlines the full range of identified potential competitors and partners and
also an outline of the scale and scope of their respective operations. DCHS has
looked to benchmark its performance with other comparable competitor organisations
but due to variance in how community providers deliver services and monitor
performance it is difficult to ensure such analysis is fair and like for like, although the
quality and reliability of benchmarking data continues to improve.
The Trust is constantly reviewing its environment to understand the changing
commissioning and competitive environment. Within Derbyshire, a collaborative
approach has been agreed with commissioners and providers to ensure we get the
best value for taxpayers by producing care in an integrated way. Local CCGs have
10
20 miles was chosen as this is the average distance travelled by patients as defined by the Care
Quality Commission.
Page | 33
confirmed that they want to work with providers to improve services. This
collaborative approach has led commissioners to confirm that they will not be
tendering community services. Their preferred option is for providers to work
together on improving care pathways, improving the safety, effectiveness, patient
experience and value for money of local services.
Within the local councils, there is a need to make significant efficiencies going
forward. They have signalled that they intend to tender most of the health related
services they commission.
This difference is manifesting itself in a form of segmentation in the market with
health services commissioned by CCGs moving towards a more partnership
approach with a view to not having competitive tendering wherever possible and
council commissioned services (Children’s, social care, etc.) moving towards a more
competitive, tendering, approach primarily in a bid to reduce costs.
The Trust has assessed the competitive threat of these commissioner intentions in
each of our service lines. A clear pattern is emerging around the risks to our
services.
Integrated Community Based Services (ICBS)
The ICBS service is an area where there is potentially significant competitive threat,
with many different types of organisations operating in this segment of the market.
This is also seen as one of the few growing areas in the health and social care
economy. However, the work we are doing around integrated care is leading to
some positive working relationships with other provider organisations. Given that
commissioner intentions are around promoting the integration of care across
providers, there is a diminishing risk around services being tendered in Derbyshire
and therefore the competitive threat. The Trust response in this area is
predominantly around further enhancing working relationships and delivering better
pathways jointly with partners. In the future we will need to consider the contract
mechanisms to support this, and this will be considered through our commercial
strategy.
Planned Care
The majority of services across our planned care service line are paid for through
cost per case contracts. There are potential competitors for this work so our ongoing
competitor analysis will be important. We are using tools, such as Dr Foster, to
identify where we can repatriate additional activity, and having discussions with
commissioners about how we can provide services closer to people’s homes, and
more efficiently. We are also working closely with Derby Hospital Foundation Trust to
support them in the delivery of their Referral to Treatment targets through the transfer
of activity from them to be delivered in our community hospitals.
Health, Wellbeing and Inclusion
The commissioning responsibility for public health related services transferred to
local Councils from April 2013. The councils have signalled they wish to tender these
services and there are clear competitive threats in this area. We are responding to
these threats through reviewing service models to deliver within the new financial
Page | 34
envelope and developing partnerships with other providers to deliver countywide
integrated offerings to commissioners.
The Local Area Team currently commission a range of Children's services. The
commissioning responsibility for these services will transfer to councils in Derbyshire
from October 2015. The councils have signalled they wish to tender these services
when they transfer which will create both opportunities and threats to the Trust. To
mitigate the risks, the Trust is working with other providers to develop a countywide
integrated service.
This analysis of the provider landscape suggests:
 DCHS is operating in an environment with significant and increasing competition
in some areas and partnership opportunities in others;
 There is a growth in vertically integrated and integrated community and mental
health organisations that could pose a competitive threat to DCHS
 However there is also a growing commitment from other organisations to
partnership working to create integrated care solutions
 Such competition and partnership opportunities could also come from private
sector organisations, smaller originations and the developing Primary Care
provider sector.
Page | 35
3.5
Commissioning Landscape
3.5.1 CCGs and Units of Planning
The commissioning landscape across Derbyshire is made up of 4 CCGs, reporting to
the Nottinghamshire & Derbyshire local area team, with a further 16 CCGs either on
or close to the DCHS border. The Derbyshire CCGs are:
 North Derbyshire (including High Peak)
 Erewash
 Southern Derbyshire (including Derby City)
 Hardwick Health
Figure 3-3 – CCGs in Derbyshire
Finnamore has been asked by the CCGs to undertake two pieces of work on behalf
of the health economy. The first is a review of planning assumptions across all
Derbyshire organisations. The second is a more detailed review of the System Plan
for the North Derbyshire Unit of Planning (North Derbyshire and Hardwick CCG).
Page | 36
Initial information from the Northern Derbyshire Unit of Planning envisages a system
that will, fundamentally, keep people:
 Safe & healthy – free from crisis and exacerbation.
 At home – out of social and health care beds.
 Independent – managing with minimum support.
Their plan is to reduce the demand for reactive episodic care by:
 Continuing to improve the impact of primary prevention
 Better meeting the needs of people who require complex ongoing care
 Eliminating unwarranted variation in access to care
When episodic care is needed:
 That the ‘right care is provided in the right setting by the right people’
 That it is provided efficiently through improved care pathways
Overall implications for the system would be:
 Delivering Integrated Care at scale to proactively support the needs of the ‘top
20%’ c.80k people
 Shifting care out of bedded services and into team based community care –
which will require major workforce changes – more generalist care supported
by specialists.
 Aligning the system to work differently – beyond existing organisation /
professional boundaries.
Commissioners in the Southern Derbyshire Unit of Planning have agreed a draft
vision for the future of services in Southern Derbyshire. Although originally focussed
on meeting the needs of the frail and elderly population, it is now intended to cover all
aspects of care, including health and social care, physical and mental health, adult
and children’s services, and planned and unplanned care.
Page | 37
They have invited providers to work collaboratively with each other and with the
commissioners to agree a radically different approach in order to achieve a stepchange in the provision of community services with the 5 year strategic aims to:
 Build strong asset based communities
 Support people to remain independent and in control of their lives
 Provide support in the community when needed and reduce the need for
hospitalisation or admission to long term care
 Improve outcomes and the quality of services provided – promote recovery
 Reduce inequalities
Their common vision, across all Derbyshire, focuses on achieving a seamless health
and social care service; at an individual level we have adopted the vision from
“National Voices”: “I can plan my care with people who work together to understand
me and my carer(s), allowing me control and bringing together services to achieve
the outcomes important to me”.
In order to deliver the changes required they intend to:
 Increase the range and take-up of opportunities for individuals to maintain
their own health and manage ill-health.
 Develop and commission children's services which prioritise early intervention
and integrated care.
 Implement changes identified in ‘Closing the Gap: Priorities for essential
change in Mental Health.’
 Expand integrated health and social care community services, based around
GP practice populations.
 Ensure 7 day per week availability of all services to prevent inappropriate
admissions and support discharge.
 Increase the range of diagnostic and treatment services in the community
 Improve appropriate access to high quality, resilient urgent and emergency
care services.
 Ensure primary medical services are developed and supported to operate at
greater scale to manage demand, improve care co-ordination and deliver
extended services.
 Improve end of life care planning and patient experience.
3.5.2 The Better care Fund
The Better Care Fund (BCF) was launched through the June 2013 spending round
and it was highlighted as a key element of public service reform. The fund is
designed to deliver better services to older and disabled people who have multiple
and complex needs, to keep people out of hospital and to avoid people staying in
hospital for long periods.
There are the six national conditions attached to the fund:
1. Local agreement
Page | 38
2.
3.
4.
5.
6.
Protection for social care services
Providing seven-day services to support services users
Improving data sharing between health and social care
Ensuring a joint approach to assessments and care planning
Agreement on the potential impact of changes to services in the acute sector.
The Derbyshire Health and social care community has prepared a joint BCF plan that
outlines how integration should be improved to deliver on four key priorities. It was
also necessary to achieve improved performance on five national indicators and one
locally determined indicator. The proposed local indicator was the estimated
diagnosis rate for people with dementia. The BCF plan was submitted to NHS
England in its final form on 4 April 2014, and for Derbyshire, excluding Derby City,
totalled £57.5m in 2015/16”
3.5.3 Derbyshire County Council (DCC)
DCC currently commissions a number of DCHS services, which include health
promotion and sexual health services. They have decided to put all the services they
have assumed responsibility for out to tender. The service solutions they will be
specifying will reflect the need to make significant savings as the DCC cost
improvement target currently stands at £157m. This poses a significant risk to DCHS
which is being mitigated through the service redesign within HWB&I service outlined
in section 5 below.
The following ‘plan on a page’ illustrates the Derbyshire CCGs’ priorities
Page | 39
Page | 40
3.5.4 NHS England
The Health and Social Care Bill extended this plurality of commissioners to include
the Health & Wellbeing Board along with NHS England, in addition to the local
authority. These supplementary commissioners commission approximately £29
million of DCHS’ income, primarily services within the Health, Wellbeing & Inclusion
division.
3.5.5 Joint Planning
DCHS has engaged and collaborated with these parties at an early stage of the
service development process. DCHS played a central role in the formal multi-agency
engagement exercise “Health and Social Care in the 21st Century” which derived the
following principles for local organisations to adhere to when considering service
development –








Continuing to improve the experiences of our patients
Achieving best possible outcomes for all
No decision about me without me
Right care, right place, right time, right provider- every time
Helping people to help themselves
Flexible and integrated working across organisations
Being innovative and not being be afraid to try new technologies, drugs,
treatments, and approaches which are based on best practice and good
evidence
Responsible information sharing while still being sensitive to confidentiality.
Key strategic aims across all priority areas will be to improve health and wellbeing by
reducing health inequalities, to strengthen investment in evidence-based prevention
and early intervention and for all partners to deliver high quality care that promotes
privacy and dignity along with robust safeguarding processes.
The Derbyshire commissioners are working on an assumption of a £260 million
reduction in funding over the next 5 year period. Commissioners continue to identify
that this gap will need to be shared both by commissioning organisations and the
providers within the county. Local CCG commissioning intentions vary in detail but
all four identify frail elderly, long term condition management and emergency
admissions in some form as the two keys areas in which to focus upon to reduce the
identified gap11. There is also a significant legacy estate which will require necessary
review alongside service models and pathways.
11
Data from NHS Derbyshire County Whole Health Economy Workshop
Page | 41
DCHS has worked proactively with CCGs to develop service models to help meet
their emerging Quality Innovation, Productivity and Prevention (QIPP) savings.
The delivery of integrated health and social care services for frail, elderly and other
people with complex needs is a key priority in Derbyshire. The CCGs have been
leading the development of new models of care across the County, with DCHS staff
and services at the heart of their plans.
The Health and Wellbeing Board has agreed to work to develop an over-arching
integration strategy to support this priority and explore how to ensure that the
necessary scale and pace of integration could be delivered.
A strategic document12 has been developed setting out a proposed approach. We
continue to work to ensure our clinical strategy and operational plans are consistent
with its direction and objectives.
The analysis of the commissioning landscape demonstrates a strong focus from the
commissioning organisations on integration, shared decision making, appropriate
care settings as close to home as possible, reducing duplication across pathways
and processes, utilising technology and ensuring optimum outcomes for the
population.
The commissioning priorities are very closely aligned with DCHS core services which
provide an opportunity for DCHS to support commissioners in delivering their
objectives for the health and social care system.
The key points of the commissioner analysis are:
 Derbyshire commissioners identified a finance gap of approximately £260
million over the 2011-2016 period;
 CCGs within Derbyshire are now well established and DCHS is well engaged
with them in further service development work;
 DCHS has worked well with the CCGs and other commissioners and ensured
good alignment between plans, for example frail elderly pathways, children’s
services and health promotion.
 The commissioning plan outlines a number of key priorities and attributes
which match DCHS service portfolio closely and therefore will form the basis
for the DCHS service development plan in section 5;
 DCHS is a significant service provider in a number of the priority areas
identified by commissioners providing an opportunity for DCHS.
12
Integration in Derbyshire: an accord – Derbyshire Health and Wellbeing Board
Page | 42
3.6
External Environment
The external NHS landscape has changed significantly in recent years not least as
the NHS faces the continued challenge of balancing financial restraint with the need
to improve quality. In addition, the Francis Report, the Berwick Review and a move
towards 7-day working, standardised staffing levels and other national services
initiatives has resulted in a significant shift to the way in which services operate and
are monitored. The revised compliance regime within the Care Quality Commission
is of significance to DCHS, not only as a service provider but as an aspirant
Foundation Trust.
Policy Context
NHS Constitution
Principles of the NHS; NHS values, rights and pledges;
responsibilities for patients, public and staff; duty of candour
NHS Mandate
2014-15
Preventing people from dying prematurely; long term conditions;
recovering from ill health/injury; positive experience; safe
environment and avoidable harm; innovation; NHS in society
NHS England
Planning for
Patients (CCGs)
7 days a week; more transparency; more choice; participation
and customer service; data/informed commissioning; improved
outcomes; standards/safer care
NHSTDA
‘Securing
Sustainability’
2014-19 (Trusts)
High quality care, delivered every time (expectations, alignment,
improvement); CQC assurance; listening to patients,
stakeholders and staff (patient engagement, staff satisfaction,
stakeholders, communities); planning for sustainable services;
supporting delivery
Monitor guidance
for the Annual
Planning Review
Working with NHS England and NHS TDA to highlight any health
economy planning divergences and dividing annual plan review
into 2 phases – operational planning (2 years) and strategic
planning (5 years)
Our service plans described in Chapter 5, Quality programme described in Chapter 6
and Workforce plans outlined in Chapter 9 are all cognisant of the national policy
agenda and have built necessary changes into our plans. In particular, the table
below highlights how a range of emerging issues have resulted in organisationalwide response to the way in which we must operate as an NHS organisation in the
21st century.
Page | 43
Issue
DCHS Response
The Francis Report

The Berwick Safety
Review




Keogh Mortality Review
During 2013 the trust had a working group to
embed learning from The Francis report. Assessment
of ongoing implementation will be made 6 monthly
This review was considered in detail and has
influenced the development of the Quality
Improvement and assurance framework
We are reviewing all our processes for end of life
care and review of patient deaths


Care Quality
Commission compliance
regime


Monitor performance
regime and changing role


Keogh Review into 7day working and urgent and
emergency services

Personal Health
Budgets


A revised system of peer review has replaced the
established provider assessment tool. This is further
supported by Board quality and safety visits and a
revised quality improvement and assurance
framework.
We are addressing this within our CFT preparations
but will need to review this as we become a foundation
trust
Our operational plan addresses this through the
proposed service changes.
We will continue to work closely with CCGs and
DCC to address the implications and opportunities that
these will present

NHS Mandate

Our service models are based on the key principles
within the mandate and we will continue to work
closely with our commissioners to secure their support
for the delivery of these models

NHS Call To Action

The impact of this is an increasing pressure to find
efficiencies across all services and pathways. We are
working with our CCGs and other health and social
care partners in a community wide response to the
challenges within this to agree integrated service
models and implement pilot arrangements; the
integrated care strategy is a direct result of this
Page | 44
In the context of our existing and emerging operating landscape, DCHS has also
undertaken a robust analysis of its wider external environment using the PESTLE
model which looks at the external environment from the perspective of political,
economic, societal, technological, legal and environmental factors.
The following section outlines this analysis and also describes the potential impact
upon DCHS.
3.6.1 Political
Political Factor
“Equity and Excellence –
Liberating the NHS” – Health &
Social Care Bill:
 Transforming
Community Services –
enabling new patterns of
provision
 “Any Qualified Provider”
 Abolition of SHAs and
PCTs with creation of
Clinical Commissiong
Groups
 Changing role of
Monitor and Care
Quality Commission
(CQC)
 Listening excercises
 Future Forum
Impact on Trust





The publishing of the NHS
Mandate (November 2012)
outling eight key objectives that
organisations should focus their
priorities to.


Trust Response
New commissioning
arrangements now in
place, but still
developing
Plurality of provision
may result in loss of
business or could
enhance
opportunities for joint
ventures
Contestability of
services (NHS,
private sector and
independent sectors)
Establishment of
Clinical
Commissioning
Groups potentially
increases the number
of customers for the
Trust
Development of
independent sector

Priorities to these
objectives by DHCS’
commissioning
organisations.
This will determine
areas in which DCHS
will need to focus
resources and service
developments

Page | 45



Development of new clinical
service models to support
local commissioning
priorities. [see section 5]
Understanding of market
place and competitors
across service lines.
Close engagement with
commissioners and
stakeholders to pursue
integrated service solutions
[see section 3]
Acheivement of Foundation
Trust status [see section
2.1]
Embedding the objectives
and areas for improvement
into service development
plans [see section 5]
The publishing of the NHS
Commissioning Board;
“Everyone Counts:Planning for
Patients 2013/14” (December
2012) outlining the key
principles to planning clinical led
commissioning from April 2013

Outlines the
incentives and levers
that will be used by
CCG’s to improve
services from April
2013, 2014 to 2016 in
Operational Plan and
5-year Plans behind
these

New Monitor strategy and
planning guidance with focus
more on organisations’ strengths
in areas that “drive long term
performance”,

There will be more
focus on individual
leadership, strategic
planning and
operational
performance
improvement.
Coalition “programme for
Increased pressure to find
government” with five high level efficiencies whilst maintaining
messages:
quality of care with focus
likely to be on a number of
 Stop top down
key areas including:
reorganisation of NHS
 Support services
 Reduction of duplication
centralisation /
and resources spend on
rationalisation
administration by a third
 Estate usage /
 Develop 24/7 urgent
rationalisation
care service
 Flexibility / usage of
 Strengthen the role of
workforce
Care Quality

Acute admissions
 Commission into an
reconfiguration
inspectorate
 Best Practice tariffs
 Develop Monitor into an
economic regulator
 Service
reconfiguration

Increasing competition and
choice of service provider




Increased local
accountability
Greater patient
control and
preference as to
where they will be
treated
Potential
fragmentation of
service provision /
portfolios
Multiple stakeholders
to understand,
manage and respond
to
Page | 46










Reflect the planning
guidance into service plans
[see section 5]
Work with commissioners
and other partners to
support delivery of these
prinicples
Ensure leadership
development is a priority
Review the planning
process in DCHS and
measure against Monitor
guidance
Support services
transformation programme
to align non-clinical services
and processes to clinical
services [see section 5]
Implementation of service
strategy led estate strategy
[see section 5]
Quality strategy and service
development principles [see
section 5]
Implementation of flexible
workforce models to support
variation in demand on
workforce [see section
Error! Reference source
not found.]
Understanding of market
place and competitors
across service lines [see
section 3.4]
Achievement of Foundation
Trust status to provide local
accountability through
membership and governors
[see section 2.1]
Continous process of market
assessment and agreement
of business development
objectives [see section 3]
Service strategies which are
efficient, effective and
economical, delivering the
right outcomes [see section
5]
Continued focus on
personalised care
 Individualised budgets



Potential loss of less
complex work and
greater concentration
of more complex work
Trust will still receive
tariff on an average
basis
Emergency
admission reduction
plans

Service strategies which
provide a flexible approach
to delivery supporting
individualisation of care [see
section 5]
3.6.2 Economical
Economic Factors
Impact on the Trust
Foundation Trust
pipeline/agenda - Commercial
culture
 “Any Qualified Provider”
model
 Increased provider
consolidation
 Introduction of NHS
Competition Panel
 Drive towards handover
of commissioning to
clinical commissioning
groups
 Contracting process for
community services


National economic climate
 requirement due to
reduced public spending
growth – linked to QIPP
agenda
 National economic
forecasts
 Deepening health
inequalities due to



Increased competition
Opportunity to become
business focused
Opportunities for new
business
Potential threat of lost
business and
associated income
Trust Response





Speed at which
change is notified to
Trust and Local Health
Economy, and
appetite /
infrastructure in place
to deliver upon
requirements
Changing role and
Page | 47


Achievement of Foundation
Trust status providing the
development framework for
increasing commercial
culture [see section 2.1]
Ongoing assessement of
the external environment in
which DCHS operates [see
section 3]
Sensitivity analysis and
assessment of financial
scenarios [see section 8.2]
Successful pursuit of new
business opportunities
Five year developed long
term financial model to
underpin business plan [see
section 7]
Service strategies which are
efficient, effective and
economical, delivering the
right outcomes [see section
5]

increase in
unemployment
Increased proportion of
income based on quality
(CQUIN)
Need for increased cost
efficiencies / CIPs
 Linked to the Coalition
“programme for
government” the Trust
will have to make
substantial and recurring
savings / efficiencies
over the period



focus of Monitor and
Care Quality
Commission
Requirement to
respond to new
standards and quality
assurance
Size of efficiencies /
CIPs to be generated
The above to be
achieved recurrently

Five year developed long
term financial model
outlines Cost Improvement
Programme requirement
over period of this business
plan. DCHS holds a good
track record of delivery
against CIP requirements
and against the wider QIPP
agenda [see section 7]
3.6.3 Social
Social Factors
Impact on Trust
Population and mix of population
i.e. demographic changes

Increasing elderly
population
 Increased life expectancy
 Increase in patients on
long-term medication and
monitoring

Increased
unemployment with
associated effects on
inequalities and
rehabilitation (eastern
side of county)
 Well informed and
affluent population
(western side of county)

Increased patient expectations
and choice







Trust Response
Impact of a growing
elderly population and
a population likely to
live longer with
illnesses e.g.
increased incidence of
dementia
More complex
requirements as age
increases
Active role in
treatment plans and
Choose and Book

Service users and
commissioners
expect high quality
Competition with
providers
Need for better
information
Marketing
Risk averse society






Page | 48
Service models which are
underpinned by robust
analysis of demographic and
population changes.
Development and focus
upon commissioner priorities
within service models, in
particlaur, development of
frail elderly and children’s
services. [see section 3.2
and section 5]
Ensuring high quality care
and the delivery of high
quality services [see section
5]
Communications and
marketing strategy [see
section 10]
Quality strategy [see section
6]
Quality account [see section
6]
Development of account
management approach [see
section 10]

Growing impact of lifestyle
issues and factors :
 Increasing levels of
obesity and alcohol/drug
related aspects
 Teenage pregnancies
 Diseases of ageing e.g.
diabetes, osteoporosis,
liver disease, certain
cancers


Emergency
Admission
Complexity of care
required
Health promotion /
Sexual Awareness
Campaigns required



Analysis of disease and
societal factors which will
affect how service are
delivered [see section 3.2]
Developing the health
promotion pathways and
integrating health promotion
into key pathways such as
children’s services.
Implement principles of
‘making every contact count’
[see section 5]
3.6.4 Technological
Technological Factors
Potential for use of
technology across service
portfolio including mobile
technology
 Commissioning
processes for
community services
 Advancement in
diagnostics,
treatments and drugs
Impact on Trust





Improved ways of
working and patient
experience
Improved speed of
diagnosis
Contribution to improved
safety
Systems training for all
employees using new
devices / technology
Increased service user
engagement
Trust Response



Utilisation of Teleheath
systems in conjunction with
increasing incidences of
long term conditions [see
section 5.10]
Utilisation of electronic
clinical systems across
services to support delivery
of effective, efficient and
economical care [see
section 5]
Trust IM&T underpinning
strategy [see section 5.10]
3.6.5 Legal
Legal Factors




Introduction of the
new Care Quality
Commission (CQC)
Increased focus on
application of
equality legislation
On-going issues
from Mental
Capacity Act and
Mental Health Act
Monitor’s role as
Impact on Trust




Changed focus and
emphasis of CQC and
Monitor respectively
Workforce planning and
management
implications
On-going training,
development and
supervision aspects
Accountability, timing
and potential impact on
Page | 49
Trust Response



Focus upon the Foundation
Trust application process
[see section 4.4] Update
based on CQC outcome?]
Focus upon workforce
across organisational
strategy. [see section 3]
A focus upon skills and
competencies and rather
than roles and job
descriptions across

economic regulator
Consultation
implications for CFT
status



CFT application
Degree of support for
the Trust’s FT
application
Events – marketing / PR
/ branding and image to
be planned and thought
through both internally
and externally
Communication
requirements

development of service
strategies.[see section 9.7]
Focus upon workforce
planning and skills analysis.
[see section 9.7]
3.6.6 Environmental
Environmental Factors
Expectation to be a good
corporate citizen
Sustainability: The NHS SDU
has released a new
Sustainable Development
Strategy in 2014
encouraging focus on
sustainable development and
adoption of good practice in
this area
3.7
Impact on Trust



Corporate responsibility
Increased accountability
Increased reporting
Trust Response



Commitment to meet
Sustainable Development
targets – already achieved
ISO standard and large
carbon emission reductions
[see section 2.6]
Carbon Management group
has Executive Director
ownership.
New Sustainable
Development Management
Plan approved by Board in
May 2014
Strengths, Weaknesses, Opportunities and Threats
The service development process has been driven not only by understanding the
external environment but also understanding the internal environment. DCHS has
undertaken a robust SWOT analysis that provides an analysis of DCHS in terms of its
strengths, weaknesses, opportunities and threats. This analysis is closely linked and
builds upon the analysis from within section 3, which focussed on the external
environment. The tables below outline the response to this analysis:
Strengths
Trust Response
Significant provider of local healthcare across a
range of community services, covering both
mental and physical health.
Build upon reputation and skills of being a local
provider of local services, as close to home as
possible. [see section 5]
Page | 50
Ability to flex resources to manage capacity and
demand requirements
Develop service models that maximise the
efficiency, effectiveness and economic delivery of
patient care to better utilise resource and improve
patient experience. [see section 5]
Strong performance
Utilise strong demonstrable record of excellent
performance in developing the DCHS brand and
portfolio, delivering service change, adapting to
change along with utilising reputation to develop
strong partnerships with other organisation. [see
section 2.6]
Acknowledged clinical expertise
Develop role of DCHS as the supply chain
manager and coordinator of care across key
pathways, such as frail elderly and children’s
services and to develop Clinical Director roles.
[see section 5]
Develop DCHS as a ‘teaching community
foundation Trust’, providing development
programmes both nationally and internationally
[see section Error! Reference source not
found.]
A culture of service innovation
Further develop this culture to support delivery of
economical, effective and efficient services
across DCHS and ensuring DCHS remains
competitive. [see section 5]
Leveraging this culture by developing DCHS as a
‘teaching community foundation Trust’, providing
development programmes both nationally and
internationally, to provide income opportunities
[see section Error! Reference source not
found.]
Weaknesses
Trust Response
Diversity of models of care and lack of
consistency across services and geography
Agreement of common principles by which DCHS
will deliver services across all divisions but also
ensures a local focus to meet local need.
Develop DCHS as a specialist community
services provider. [see section 5]
Dispersed estate with wide variation of quality
Developed estate strategy which is driven by
service strategies and service need with a focus
on rationalisation rather than maintaining existing
infrastructure which may not be in the right place
or to the right quality. Ensure that service
models are developed around care being
delivered as near to the service user with
Page | 51
domiciliary care being the default where clinically
indicated. [see section 5]
Evolving commercial expertise and application
Develop commercial approach to the business
building upon the work already undertaken
around SLR and business development.
Development of service/profit centres linked to
further application of SLR and SLM [see section
7]
Inconsistency of relationships and partnerships
with some GPs in the catchment area
A significant level of engagement has already
been commenced through the service
development process with GPs and CCGs. This
maybe further developed through joint working
and partnership opportunities around future
tenders and also potentially the provision of
primary care services
Opportunities
Trust Response
Development of core and new business
Use of business development framework to guide
and support the expansion and development of
service portfolio. [see section Error! Reference
source not found.]
Rationalisation and improvement of estate
Developed estate strategy which is driven by
service strategies and service need rather than
maintaining existing infrastructure which may not
be in the right place or to the right quality. [see
section 5]
Opportunity for developing new partnerships and
ventures.
DCHS has developed a business development
strategy which outlines the areas for opportunity
in which to leverage partnerships [see section
Error! Reference source not found.]
Increasing service user, carer and public
involvement through Foundation Trust
governance arrangements.
DCHS is clear that the governance arrangements
of a Foundation Trusts is a key element of
achieving our strategy and have developed a
plan on how best to utilise. A membership
strategy has been developed to maximise the
benefits of membership and a successful
recruitment campaign undertaken.
Page | 52
Usage of telehealth and telemedicine to deliver
our services to our dispersed population and to
support the drive for efficiency and effectiveness.
DCHS considers that telehealth and telemedicine
could be a key component of its service strategy
and play an integral role in delivering high quality
and effective care. A pilot is currently being
evaluated across Heart Failure services [see
section 5]
Expand complex mental/physical care expertise
in growing market.
DCHS has identified that that this is an area in
which to develop both in existing markets and
into new markets. This is also a key area in
service development plans as a priority for
investment and development [see section 5]
Threats
Trust Response
Commissioner intentions and management of
demand in a changing commissioning landscape.
Robust market and external assessment to
enable forward planning and development of
mitigation plans. Service strategies also
developed to take this into account [ see sections
3 and 5]
Financial challenges at national, regional and
local levels.
Full and comprehensive financial modelling
undertaken driven by the service development
plans [see sections 5 and 6]
Failure to reach Foundation Trust status.
DCHS is clear that becoming a Foundation Trust
is not the end in itself but rather an important
foundation on which to develop and has put a
robust structure to ensure achievement. [see
section 4.4 and 8]
Failure to maintain performance
Given the significant challenges DCHS
acknowledges that is more important than ever to
ensure DCHS continue to deliver the high
performance it always has done. Therefore the
overall corporate governance arrangements have
been reviewed along with performance
management framework. [see section 9]
Serious Incidents (SIs) and a loss reputation
DCHS is committed to ensuring high quality and
effective care and has undertaken a full review of
clinical governance processes and systems to
mitigate this risk [see section 8 and section 9]
Loss of business to other providers, in particular
local established Foundation Trusts
DCHS has undertaken a detailed analysis of its
competitors [see section 0] and has a number of
initiatives in place to counter this risk [ see
section 8]
Page | 53
Key points of this section:

The local health economy across Derbyshire and beyond demonstrates a
contrast in demographics and well-being, having communities both in the
lower and upper quartiles for deprivation. DCHS is well placed to respond
to this by the development of locality based service models.

Derbyshire has a significantly higher than average age profile, which will
increase over the next five years with associated increase in long term
conditions. DCHS has modelled this through its planning assumptions.

DCHS is well thought of by emerging clinical commissioning groups, and
they want to engage in a positive working relationship.

DCHS will be operating in a significantly more financial constrained
environment with an increasing demand on services.

DCHS operates in an environment with a plurality of providers and has a
range of measures in place to position it as a responsive and successful
provider.

DCHS performs well in comparison with identified competitors.
Key actions from this section:
In response to the analysis DCHS has:

Developed service plans that not only meet the demographic needs but also
fit within financial envelopes of commissioners;

Developed frail elderly services with flexible capacity and improved access
to respond to increasing demand on services, and deliver services required
by this cohort of population;

Developed a stepped pathway approach to long-term condition
management, with increased community and specialist teams providing a
more timely and robust response;

Developed strategic partnerships where appropriate to mitigate against
competitors attempting to move into areas of DCHS core business. Along
with develop effective and positive relationships with commissioners;

Developed the capacity and capability across children’s services to be able
to support families;

Included levels of innovation such as use of agile working, telehealth and
Page | 54
new models of care to ensure efficient and effective services;

Ensured that services are being delivered effectively and efficiently and
meeting commissioner and service user outcomes in a responsive and
innovative way;

Continued with CCG engagement and convergence and continue to ensure
DCHS service development plans deliver desired outcomes and are
focused on priority areas.

Continued to develop the business development processes to ensure DCHS
can respond to a rapidly changing market.
Page | 55
4
Strategy
Purpose of this section:
4.1

Describe the strategic context of DCHS;

Describe the vision of DCHS;

Set out our strategy, including objectives to deliver the vision;

Outlining how achieving Foundation Trust status will support achieving our
vision.
Context
DCHS’ strategic framework, which includes its vision, values and objectives, has
been developed following the in depth analysis outlined in section 3 which covered:
•
•
•
•
The market in which it operates and its competitors,
The policy context
The demographic implications
Commissioner priorities and the financial challenges
Within the context of this analysis and the service priorities, which have emerged
from the subsequent SWOT and PESTLE process, DCHS has worked closely with its
staff to develop a clear vision for the organisation and to agree a set of underpinning
principles and values that will help to support the change process.
4.2
Vision
Derbyshire Community Health Services NHS Trust aims to be the best provider of
local healthcare and to be a great place to work. This vision emphasises the close
relationship that exists between empowering and supporting our workforce and being
able to deliver the best in local healthcare.
DCHS has thought carefully about what the services and organisation will look like in
5 years when this IBP has been implemented. In this respect, what matters most is
the experience of patients and their families and carers. Currently, there are plenty of
examples of excellent practice, but by 2019 any variation in care models should be
eradicated. The 3 patient stories below paint this picture more clearly than anything
else can.
Page | 56
In 2014, Annie, the 78 year old who fell in her garden one Friday evening, spent
more than 2 weeks in an acute hospital 12 miles away from home and a further 2
weeks in a community hospital and her daughter found it impossible to visit her. In
2019, the GP rings the single point of access which arranges for her to be assessed
in a local assessment and diagnostic centre where her physical and mental health
needs are addressed. She is admitted to a treatment centre for just one day before
being discharged to be looked after by one of the new multi-agency integrated
community care teams. The team, supported by telecare, and with Annie’s daughter,
have successfully looked after Annie in her own home for 7 months.
In 2014, 6 year old George is thought to have attention deficit disorder and has had
11 different assessments undertaken over a couple of years by the GP, health visitor,
school nurse, social worker and someone from health promotion. He and his mother
have to go to 5 different locations. In 2019, George and his mother are being seen in
a children’s centre by a multi-agency team, including health promotion, using a
common assessment process.
In 2014, Indira has a degenerative muskulo-skeletal diagnosis. She sees the
orthopaedic, podiatry and physiotherapy teams in 3 different places and times and
has to make yet another appointment if she needs any diagnostic tests. In 2019, she
is seen in an integrated common assessment & treatment service (ICATS) where she
can see all the specialists and get her tests on the same day in the same place.
In the same way, our organisation will look very different in 5 years’ time. In 2019, our
patient and staff feedback will rank us as one of the top Trusts in the country in
recommending us to their families and friends. We will have expanded our service
provision into neighbouring counties and will be competing in some of our planned
care services with private sector companies.
In 2019, we will have delivered our long term financial model, notably our cost
improvement programme, while continuing to transform our service models and
improve quality as the patient stories above demonstrate. Our estate and IM&T
strategies will have been delivered as an integral part of delivering the new service
models.
4.3
Strategic Objectives
Building upon our understanding of our local populations, the external environment in
which we operate and our own internal organisation we have developed a number of
strategic objectives to achieve our vision of being the best provider of local
healthcare and being a great place to work:

To deliver high quality and sustainable services that echo the values and
aspirations of the communities that we serve;
Page | 57

To build a high performance work environment that engages, involves and
supports staff to reach their full potential;

To ensure an effective, efficient and economical organisation that promotes
productive working and which offers good value to its community and
commissioners.
The diagram in Error! Reference source not found. Error! Reference source not
found. outlines DCHS’ strategic framework which shows how objectives are linked to
delivering the DCHS vision. This strategic framework is supported by the DCHS Way
[see section 2.3] ensuring that our organisational objectives are tied into our
organisational processes and systems.
Figure 4-1 - DCHS Strategic Framework
Underlying our strategy has been a fundamental debate about why the Trust should
exist. We believe passionately, supported by our commissioners, primary care and
council colleagues, staff and many other partners too, that a specialist community
services provider Trust is an invaluable part of the local health and social care
community because it is unique in:

Being the only organisation operating across the County which has the provision
of community services at its heart and so is able to co-ordinate the on-going care
for patients being discharged from the 13 acute Trusts in and around Derbyshire;
Page | 58

Having the skills to care for people who may require a range of support from an
on-going long term relationship in their home to an outpatient appointment in one
of our treatment centres;

Aiming to not just provide care but also promote the health and well-being of all,
promoting independence and opportunity wherever possible;

Being able to meet a significant patient service gap between certain patient
groups’ need for urgent care and an acute referral. This includes patients with
long term conditions and elderly confused patients.

Through the provision of a range of consistent and coherently managed
integrated services, providing high quality patient services;
o Without the need of a bed
o Close to home
o Without the additional expense of domiciliary services

Being able to act at individual patient and care pathway level as care co-ordinator
/supply chain manager across the statutory and voluntary sector to deliver ever
more integrated care for patients and their families as evidenced by the Kings
Fund and Nuffield Trust13;

Planning to offer a well organised range of services delivered from effective
treatment centres which will enhance community provision and lower the cost of
healthcare delivery for patient groups where demand is growing leading to
increased potential cost to the NHS;

Acting as an important part of commissioners’ market management strategy in
providing an alternative choice of provider for patients and referrers.
In order to meet the DCHS objectives a number of key deliverables for this IBP have
been identified with associated key performance measures to ensure DCHS can
monitor achieving its objectives and vision. The tables below outline these
deliverables building upon analysis in section 3:
Where next for the NHS reforms? The case for integrated care – Available from:
http://www.kingsfund.org.uk/publications/articles/nhs_pause_paper.html
13
Page | 59
Objective
To deliver high
quality and
sustainable
services that
echo the values
and aspirations
of the
communities
that we serve
Objective
To build a high
performance
work
environment
that engages,
involves and
supports staff
to reach their
full potential
Key Performance
Measure
Key Deliverables

CQUIN Measures

Early Warning
Indicators

Referral to
Treatment Times

Patient Reported
Outcome Measures

Complaints &
Compliments

HCAI Rates

Harm Free Care
measures
Providing frail elderly services
across redesigned pathways in, or
as near to people’s homes as
possible.
Integrated working with the local
councils to provide seamless
services for children’s and families.
Developing an integrated planned
care service to avoid patients
having to make multiple visits.
Providing efficient, friendly and
effective services in appropriately
located premises which are fit for
purpose and easy to access
Key Performance
Measure
Key Deliverables

Staff survey return
rate

Staff satisfaction and
recommendation
scores

Attendance rate

Appraisal completion
rates

Staffing for Quality
measures

Annual essential
learning programme
completion rates
Page | 60
Delivery of five year workforce
transformation and associated
enabling strategies.
Embed teaching culture within
DCHS and gain external
recognition.
Achieve DCHS staff engagement
targets as outlined in Engaging the
DCHS Way.
Develop reward and recognition
levers to highlight where
staff/departments have gone the
extra mile.
Objective
Key Performance
Measure

To ensure an
effective,
efficient and
economical
organisation
that promotes
productive
working and
which offers
good value to
its community
and
commissioners.






Key Deliverables
Delivery of estate strategy and
required changes.
Income and
productivity
metrics
Tender success
rate
Delivery of support services
transformation programme.
Achievement of annual financial
plan as part of LTFM.
Percentage of
projects accepted
Implementation of quality strategy
into PMO
across DCHS
Overhead cost of
estates
Consolidation of PMO
Support services
productivity
released
‘Top X’ Risk
Identification
Continuity of
Services Rating
Implementation of IM&T Strategy
Implementation of Commercial
Strategy
This strategy underpins the development of this Integrated Business Plan which sets
out the scale of the challenges our services face over the next five years, the
transformational change required to meet them and why we believe we are in a
strong position to meet them.
DCHS is uniquely placed to meet the increasing priority given to promoting health
and wellbeing through the range of service it offers and through its strong
commitment to delivering services which promote health and independence, and are
aimed at reducing unnecessary and inappropriate acute and specialist hospital
admissions.
DCHS delivers integrated services in the communities it serves which are locally
organised and which can help people to receive seamless health and social care and
co-ordinated primary, community and secondary care services, with close working
with health and social care.
Page | 61
4.4
Approach to Business Development
Through the analysis of the business environment in section 3, which included the
commissioning landscape, a competitor review, PESTLE analysis and an internal
analysis of internal strengths and weaknesses, DCHS has been able to review the
potential markets in which it may wish to operate.
The key principle that underpins this analysis is the DCHS commitment to the
provision of the most effective and high quality services for the communities of
Derbyshire. This then forms the basis upon which any decision will be made as to
whether DCHS also pursues opportunities in adjoining areas to those currently
served. As such it will seek to do this where it feels it is best placed to provide these
services and has the skills and experience to do so to a suitably high quality.
Where there are opportunities to expand, these will be considered in relation to the
provision of pathways of care, comprising elective, rehabilitative and long term care
services, outside Derbyshire and adjacent to where we currently provide services
and where this is consistent with the DCHS investment policy. This has previously
been done in relation to Planned Care services in Leicestershire and Rutland and as
it continues to do in relation to Community Dental services within the same area [see
Table7 - Ansoff Matrix for further detail].
In addition, DCHS is aware that there may be opportunities to expand further beyond
its current income base through merger or acquisitions, given the rapidly changing
market place and financial environment. Again, the commitment remains to being the
best provider of services to the Derbyshire community first and foremost and any
decision to pursue such opportunities would be based on a careful consideration of
the transaction costs involved.
DCHS is, however, clear that form should follow function and that service solutions
should be those best suited to the needs of the patients, not simply a continuation of
current traditional provision. In seeking such solutions DCHS looks to be a system
leader and prioritises collaboration over competition. As such, the pursuit of new
services and markets as a single organisation may not always be the best solution
and working in partnership with the wider community may therefore be essential.
This ensures that the organisation with the right skills and experience provides the
care where it is most appropriate. To this end DCHS continually scopes its
partnership opportunities and networks closely with other organisations that may be
willing and suitable to collaborate with. DCHS also continually reviews it services to
ensure it understands where it may not be best placed to provide them and where
other organisations should perhaps undertake this instead. As such DCHS has
already divested itself of Patient Transport Services and Specialist Stroke
Rehabilitation services.
Page | 62
4.4.1 Summary Service Strategy
DCHS wishes to maximise its contribution at the centre of local healthcare delivery,
working in partnership with organisations across a wide range of pathways across
the health community.
The resultant model of provision and associated contract may vary whereby DCHS:



Is the lead provider of services, working in collaboration or non-formal integration
with others
Works in effective alliances or formal partnerships where this is of benefit to the
patient and pathway
Operates in a sub-contractor role where another organisation is lead provider
The DCHS frail elderly service model will see it:





Continuing to operate off a smaller, leaner, specialised bed base
Providing intensive and complex clinical care from these beds
Supporting the provision of acute, specialist inpatient care across the health
and social care community through a network of holistic, community teams
who provide support in settings ranging from patients homes through to
inpatient assessment, care and support
This will include greater integration of our physical and mental health services
to ensure that every contact provides an opportunity to improve a patient’s
medical condition or health outcomes.
Operating from a smaller estate, where we retain our best facilities and
concentrate specialist, inpatient care on fit for purpose sites
Our health and wellbeing delivery model will see us:



•
Remodel health promotion services to reflect the council’s wellbeing
service/healthy lifestyles model, including the introduction of the generic
wellbeing support worker roles
Integrate Sexual Health Services with Contraceptive, Sexually Transmitted
Infections and Genito-Urinary Medicine services across Derbyshire and Derby
City in advance of the scheduled re-procurement exercise.
Fully implement the Healthy Child Programme and development of an
integrated model with Education and Social Care through our health visiting
and school nursing services
Implement learning from the Family Nurse Partnership to provide targeted and
focussed resources to specified vulnerable parents.
Page | 63
Our planned care and outpatient’s delivery model will see us:



Align with our frail elderly integration by providing services in
primary/community settings where that is appropriate and continue to seek
opportunities to bring consultant outpatient closer to home, linking with
community assessment and diagnostics services where required
Target commissioned growth in elective care where that is appropriate as a
result of demand and/or demographic growth, and where that is contracted for
by volume.
Evaluate our ICATS service model in order to see continuous efficiency and
quality improvement
4.4.2 Clinical & Service Principles
Within the context of the DCHS vision and values it’s clinical strategy and service
delivery plans will be based on the principles developed through discussions with
local people as part of the multi-agency 21st Century Health & Social Care
programme. These are:

Person-centred services…meeting the needs of the person and their families
or carers rather than the needs of the system

Provide care flexibly…across all health and social care organisations by
listening to, and understanding the person’s complete needs and meeting them
by using all services and resources available

Challenging assumptions…about the way we work and have the courage to
make changes for the better that will improve the patient experience and obtain
the best value for money

Respect and value people…who use and work in health and social care
services in Derbyshire

Actively seek and listen to the views of people…who use and work in
health and social care in Derbyshire

Support people to make an informed choice…about lifestyle and services
and identify and provide extra support for those who need and want to make
positive lifestyle changes.
Through this approach we aim to provide first class community services to our
population, which deliver sustainable high quality clinical care provided by welltrained, well-motivated and well led staff covering 7 days of the week. We are
Page | 64
however clear that this strategy will continue to require significant service redesign to
deliver the necessary change whilst improving quality and delivering the
organisations Cost improvement Programme and further community wide efficiencies
commissioner QIPP. Further details of the clinical and service developments
strategies can be found in chapter 5.
4.4.3 Business Development and Investment
DCHS has developed a business development framework and investment policy and
has used SWOT and PESTLE analysis to strengthen its understanding of, and
response to, the rapidly changing market. This framework encapsulates the resultant
commercial aspirations of DCHS which are to be a:




Flexible and responsive provider willing and able to listen, design and deliver
services to meet the needs of patients and commissioners at locality level
Problem solving organisation which will be a willing and effective partner
where a multi-agency solution is best for service users
Truly integrated member of the Health and social care community which is
able to manage patient pathways and coordinate cost effective service around
patients and within their own communities
Class leading provider of high quality and innovative care which benchmarks
for excellence and invests in its workforce
Building on this a Commercial Strategy has been developed to:






Clarify the Trusts commercial purpose
Describe the Trust’s approach to growth and the principles which will inform
this
Establish the trust’s approach to influencing the commercial environment in
which it operates,
Drive the appropriate marketing, branding, and relationship management
approaches
Ensure the organisation systematically captures and uses patient experience
to inform it’s approach
Outline the associated organisational development work being undertaken to
achieve the strategy
The Ansoff Matrix [Table below] which underpins this strategy outlines where
DCHS considers it needs to focus its attentions in terms of its business
development approach, building upon its strengths and the opportunities that its
market provides:
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Existing Market
New Markets
Derbyshire County and City
Outside of Derbyshire




New Services
Existing Services




Focus upon long term conditions and
integrated community based services.
Expand children’s services into areas
currently not covered by DCHS
Expand physiotherapy provision into the
south.
Develop partnership with other providers
for provision of learning disability and
mental health services across
Derbyshire County and Derby City.
Develop:
 Providing enhanced input into care
homes.
 Soft and hard facilities management
provision further into both NHS and nonNHS markets.
 Extend reablement activity and
specialist palliative care provision.
 Co-ordinate lead provider for continuing
care provision and expand current
continuing care provision.
 Explore social care provision
Podiatry and podiatric services
Planned care and specialist services
Health and Wellbeing Services
Specialities such as dental, speech and
language, contraception and sexual health
services which may operate as regional
specialities.
DCHS will consider delivering any of its current
services in:
 Geographic areas which are adjacent to
where we currently deliver services,
 where DCHS currently delivers this service
as part of core business,
 and can deliver the pathway in the most
effective and efficient way, maximising
outcomes and adding value,
 and meets the criteria of the decision
making tool.
DCHS is not considering entering new markets
with new services.
Table 7 - Ansoff Matrix
4.5
Towards Foundation Trust Status
DCHS undertook a significant consultation process during 2008/09 and again in
2010/11 to consider the organisational model options available as part of the
Transforming Community Services programme. This process confirmed strong
support from staff, commissioners and other stakeholders for establishment as an
NHS Trust and through due process a Community Foundation Trust. This decision
was taken as it was felt that becoming a Foundation Trust fits best with the vision and
ambitions of DHCS, as well as best supporting the achievement of organisational
objectives.
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DCHS believes the governance arrangements, freedoms and accountabilities of
Foundation Trust status will enable DCHS to make the transformation in our services,
people and organisation as described throughout this plan. Nonetheless, the
organisation is clear that Foundation Trust status should not be an end in its own
right but be pursued because it provides the best way for us to deliver our vision and
improve both local health services and local health.
The benefits expected from the freedoms and accountabilities afforded by
Foundation Trust status will ensure new opportunities to take forward our strategic
objectives and to achieve our vision and ambitions:

To enable the organisation to respond more effectively to the challenges of
increasing patient expectations combined with a more competitive and financially
constrained environment. DCHS has strived to adopt Foundation Trust working
practices since its inception to foster and develop the mind-set and culture for
services to think strategically about the external market and environment that
they operate in.

To provide a longer term approach to financial planning which allow greater
freedoms to develop services, operate in line with competitors and to support the
productivity and efficiency agenda. As DCHS moves into a more financially
constrained environment with increasing competition and less absolutes on levels
of income the financial freedoms will provide DCHS with the opportunities in
which to mitigate these risks.

To support a more commercial model of operating to allow DCHS to actively and
confidently compete in an open healthcare market. DCHS already is committed
to developing its approach to business development and pursuing new
opportunities, becoming a Foundation Trust will further support the development
of a commercial and business approach.

To allow increased input from staff and the public through the membership and
governor framework to ensure that we develop and deliver our services in line
with service user, public and staff expectations. Since its inception DCHS has
strived to develop a culture of staff and stakeholder involvement, the introduction
of the membership and governor model will allow this culture to be developed
and moved on to the next level.
A key driver for pursuing Foundation Trust status is that of the membership scheme
and Council of Governors. This will provide new ways for people from Derbyshire
and other areas where services are provided to influence the Trust’s success. DCHS
intends to seek to achieve this through an active public and staff membership and a
Council of Governors, which is fully engaged and involved in the development of the
organisation. DCHS has been actively recruiting to our public and staff membership
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scheme since July 2011. As at April 2014 DCHS has over 17,000 members: 12,200
public members and 5,000 staff members.
The membership scheme is also the mechanism through which DCHS will become
actively involved in the local communities we serve. As a large employer and as an
organisation which is invited to play a part in the lives of so many people, DCHS is
strongly committed to playing a wider role in supporting local people and our partners
to improve their health, their wellbeing, and their communities.
DCHS acknowledges that in many organisations the membership is a means to an
end in becoming a Foundation Trust; however DCHS considers the membership and
the establishment of a Council of Governors as a key enabler to being a successful
organisation and is committed to their continual development and involvement.
DCHS intends to utilise these mechanisms to:

To involve and engage with the Trust, in a way that recognises the value of their
ideas and opinions.

To engage the local community through community visits to a wide range of
groups and stakeholders.

To improve and ensure an understanding of DCHS and its relationship to the local
community.

To ensure that DCHS is accountable for its performance to its members, as part
of its commitment to the local community.
DCHS also identifies that the role of Governors will bring unique benefits to the
organisation over and above the statutory responsibilities within a Foundation Trust.
It is planned that Governors may carry out specific tasks and projects in line with
future plans, such as recruiting members and being members of DCHS project teams
or boards as appropriate. Governors are supported to develop their role and
understanding of DCHS and the wider NHS and are offered training and support to
help them. To this end DCHS has developed its strategy to fully exploit the Governor
role across DCHS. This will be developed by the governors to ensure that they are
able to shape the role that they wish to play within the organisation.
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Key points of this section:

The vision sets out the organisation’s commitment to delivering the very best
community services to our communities;

DCHS is a unique organisation ideally placed to provide community services
and co-ordination of care;

Our strategy is based upon the three themes of ensuring quality service,
quality people and quality business;

Achieving Foundation Trust will provide benefits for service users, the health
community and the organisation;

These key principles underpin the service development plans outlined within
the next chapter.
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5
Service Development Plan
Purpose of this section:
 Describe the plans DCHS has developed for its services to be able to
respond to the challenges identified through the analysis in section 3 and to
deliver the organisational strategy outlined in section 4
 Outline the underlying assumptions and drivers for these plans;
 Outline the assurance framework that has been developed to ensure delivery
of the service development plans.
DCHS delivers a range of community and specialist services, including adult and
children services, elective planned care, and a range of specialist services such as
dental and sexual health. These services are closely aligned with the commissioning
priorities identified in section 3. DCHS is well placed to ensure its service
development plans support commissioners to deliver their overall priorities.
DCHS has a strong track record of delivering against performance requirements and
continuously improving and developing its services. However it will need to build on
this reputation to ensure it meets the challenges outlined earlier particularly the
increasing proportion of people over 65 and the associated increase in long term
conditions. All this will be set within the context of reduced levels of funding and the
imperative to maintain quality and improve patient outcomes.
The development plans that DCHS has developed will build upon the existing service
models and will align with commissioners and service user’s requirements to ensure
that these services can continue to deliver the required outcomes over the lifetime of
the plan. To achieve this, a number of service development principles have been
developed in response to the previous analysis in chapters 3 and 4 which will
underpin our plans:




Providing a Single Point of Access (SPA) & clinical navigation– to ensure
that it is quicker and easier to use and access our services for both referrers and
service users and to ensure a rapid referral to the most appropriate service for
the service user;
Providing responsive care as close to home as is appropriate – by ensuring
domiciliary care at home is the default to support people more in their own
communities, using in-patient care only where it is clinically indicated;
Creating service and pathway provision that is integrated across our own
services and with those of our partners – by reducing hand-offs between
organisations and ensuring joined up care and giving more control to patients;
Ensuring all services promote health and independence – by treating service
users in a holistic way that helps prevent illness and promotes good health, along
with reducing health inequalities;
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
Providing quality care which is efficient and sustainable – and that all
processes that underpin and support the delivery of care are delivered through
an integrated model of provision based on recognised best practice

Ensure care is safe, provides a good patient experience and is clinically
effective – using evidence based clinical interventions and through a process
which has addressed the risks to the organisation and the impact on quality.
Throughout the analysis in section 3, the development of the strategy in section 4
and the formulation of these principles, a consistent dialogue has been maintained
with managers and clinicians as to how best the services could be re-modelled to
deliver the desired outcomes. This has resulted in the identification of a number of
programmes of service change which are in turn supported by enabling programmes
across workforce, IM&T and estates. Delivery will be structured around a
comprehensive range of projects which will be supported by the Project Management
Office outlined in section Error! Reference source not found..
DCHS has a commitment to innovation and a track record of delivery. We updated
our existing strategy in the light of the national innovation report14 in order to support
a culture of innovative working and also to create systematic delivery mechanisms
that better promote adoption and spread across the organisation. Through this we
will identify and mandate the adoption of high impact innovations in the NHS and
spread and adopt innovative practice that will deliver a better service and better
outcomes for patients.
This in turn will be supported by our Improving Leaders Programme (ILP) which was
established in 2009 to promote service productivity through the use of proven
improvement techniques and the promotion of effective leadership. Already more
than 300 leaders have been through this programme and an impressive record of
service and cost improvement has been achieved. This approach will continue to be
pursued to underpin the redesign of services and to promote best practice and
service efficiencies.
These programmes are now described below in respect of the services covered, the
identified case of need, the resultant service models and the delivery projects that
underpin them.
5.1
Frail Elderly
5.1.1 Services Included

14
In-patient Elderly Care &
Rehabilitation


Community matrons
Minor Injury Units
Innovation Health and Wealth - Acceleration Adoption and Diffusion in the NHS
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


Community Therapy
Older Persons Mental Health
Community Nursing


Day Services
Specialist services, e.g.
continence, diabetes,
heart failure
5.1.2 Case for Change
The key demographic changes highlighted in section 3.2 present a number of key
challenges to the frail elderly services within DCHS. This highlights a 63% increase
in the number of people within the 65 year old and above age range over the next 20
years. This will therefore be coupled with an increase in the incidence of long-term
conditions and other health and social care issues that are common with the frail
elderly population. These include the incidence of mental health and dementia,
which in Derbyshire, lies above the regional and national averages.
These trends are supported by national clinical policy (See Quality, Section 6.2) and
the NHS Outcomes Framework15 identifies five domains for demonstrating quality
outcomes:





Domain 1: preventing people from dying prematurely
Domain 2: enhancing quality of life for people with long term conditions
Domain 3: helping people to recover from episodes of ill health or following
injury
Domain 4: ensuring that people have a positive experience of care
Domain 5: treating and caring for people in a safe environment and protecting
them from avoidable harm
These five outcome domains will be driven through the quality standards and via
contracting/commissioning and payment mechanisms that further reinforces the
importance of this framework and its impact on the service development plans.
Along with the health and social care drivers there are significant financial and
efficiency pressures upon the system, particularly in services caring for the elderly
population. Current models of service delivery are therefore not sustainable given
this need to deliver services for an increasing elderly population within a decreasing
level of funding, whilst ensuring high quality and meeting desired outcomes.
Commissioners have outlined the frail elderly as a key priority area within their
commissioning intentions, and this is supported by individual CCG plans. These
plans include improved integration between primary, secondary and social care and
the reduction of emergency admissions across the County.
There is a growing body of evidence supporting home-based care showing these
can be at least as safe and effective as hospital settings:
15
NHS Outcomes Framework – Department of Health
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Admission avoidance
 Significant reduction in mortality at 6 months
 Less expensive than acute hospital care (excluding informal care)
 Increased patient satisfaction
 Possible increased carer satisfaction
Early discharge
 Significantly less likely to be in residential care at 6 months
 No significant difference in mortality
 For patients following stroke, no difference in re-admission rates
 Increased readmission rates for older patients
 Increased patient satisfaction
5.1.3 Service Aims
In response to the above drivers the aim of the frail elderly strategy is therefore to:






Provide care as close to patients’ homes as is clinically appropriate and practical
Enable a seamless journey throughout DCHS services, ensuring that patients get
the most appropriate care as close to home as possible.
Allow easy access into these services for referrers and patients.
Provide a case management/clinical navigation service to all patients regardless
of where they enter the pathway.
Co-ordinate care, particularly across interfaces with acute care, primary care and
social care.
Reduce duplication, variation, and patient hand-offs between services and
professionals.
Our future service model will thus see DCHS:
 Provide more care in the community structured around community support
and integrated teams that provide quicker access to patient focussed care
and promote independence and wellbeing
 Continue to operate from a smaller, leaner, specialised bed base where we
retain our best facilities and concentrate specialist, inpatient care on fit for
purpose sites
 Support the provision of acute, specialist inpatient care across the health and
social care community through a network of community teams who provide
support in settings ranging from patients homes through to inpatient
assessment, care and support
5.1.4 Service Model
Within the original IBP a tiered model of provision of services for the frail elderly was
proposed and this is shown below.
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Figure 5-1 – Tiered Service Model
This model was based on a Hub and Spoke arrangement of Assessment and
Diagnostic centres supported by Treatment centres across the county. The intention
was to provide these in suitable locations so that local access would be maximised
and also so that they would complement the geographic model that DCC were
proposing for their Community care centres and extra care housing provision. The
proposed DCHS locations are illustrated on the map below:
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This model has now been further developed through a continuing dialogue with the
CCGs, DCC and our other key stakeholders. This has led to a revised model through
which we intend our care to be more holistic and increasingly integrated with primary,
acute and social care. There will also be greater integration across our physical and
mental health services, which will retain a speciality focus, but which will also be
mutually supportive in meeting patient’s needs. We remain committed to ensuring
that our model complements that of DCC and this will see us integrating our provision
across a number of sites which are shown on the map below which depicts the new
model of frail elderly service provision:
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This will be based on a 5 tier model of provision (shown below) which has been
agreed across all 4 Derbyshire CCGs and also agreed as part of the Derby City and
Derbyshire County Better Care Fund planning. The DCHS response to this will
however be tailored to meet the specific requirements of the different CCG localities.
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Figure 5-2 – Agreed Derbyshire-Wide 5-Tier Model of Provision
The purpose of this model is to engineer a step change in the following:
1. Increase the number of people who avoid formal care and support because
they have their needs met through natural community support
2. Decrease the number of people with a long term condition(s) living without an
informal network of support
3. Increase the role of peer support and educators to help people manage their
condition and recover
4. Significantly reduce the number of unplanned admissions to hospital and care
homes through effective admission avoidance interventions
5. Increase recovery outcomes across all client groups through increased and
improved recovery services
6. Significantly reduce the number of people going into long term care from a
hospital bed
7. Reduce delayed discharges through increased community-based services
and effective care pathways
8. Provision of timely and effective support to carers
The refined DCHS approach is based on its newly formed clinical strategy which
encompasses the following key principles:
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













Using inpatient beds only if treatment at home is inappropriate from either a
clinical or social perspective
Recognising the potential clinical risks associated with in-patient care we
should do all we can to minimise length of stay as much as possible and use
an environment as close to home as possible. This should encourage
continuity of care and ensure our community hospitals also support patients in
the community as well as on our wards
Creating a workforce based around Advanced Nurse Practitioners (ANPs) as
the principle providers of the holistic patient care we need in our community
hospitals
Developing close clinical integration with acute trusts, working to avoid
inappropriate community admissions of undifferentiated patients due to safety
and quality issues
Providing an environment in which nursing staff feel they are given a clear
career progression across inpatient and community settings and where the
focus is on recruitment, retention and development of nursing posts
Supporting the development of the community geriatrician model which
facilitates seamless transfers of care across the health and social care
community
Supporting the development of the community support team model of care,
particularly involving ANP, community matron and community geriatrician
support
Continue to support the development of the adult reablement unit (ARU) to
enable prompt diagnosis of frail elderly people and to facilitate their pathway to
appropriate setting dependant on the acuity of their needs. This will involve
integrating with the rapid assessment units in both acute trusts to facilitate
rapid turnaround of frail elderly using our Single Point of Access teams to track
patients and navigate them to the correct destination appropriate to the acuity
of their need
Creating a model for clinical governance that supports a team within the
community setting
Ensuring that we continue to support the national expectations and good
practice in terms of staffing for quality
Continuing to support the development of the quality dashboard and
supporting assurance framework
Continuing to develop the model to support the provision of safe and equitable
care across the seven day period, i.e. providing seven day services
Working to minimise duplication and data collection generally to provide more
time for front line staff to care for patients
Analysing the generic range of skills vs specialist skills to minimize the hand
overs of care in order to increase capacity, particularly in the community teams
5.1.5 Delivering the Model
DCSH has refined its service model to match the requirements of the CCG, both
through the agreed county wide model above and also through taking account of
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local variations in need and the provision of a flexible response to these. This model
describes the tiered approach:
Figure 5-3 – Tiered approach to provision of services
This model will be supported by the Single Point of Access (SPA) function which has
been implemented across the county. They ensure streamlined access into DCHS
services with an integrated care package which could include care in a community
hospitals, in patients own homes or at nearby local health and social care facilities.
The SPAs also have the lead role in coordinating the interface with the acute
services. They are evidencing an increased level of avoided admissions and an
increase in the number of patients being treated in settings closer to home and their
impact will continue to be evaluated. We are also partnering with the Voluntary
sector SPA which will provide signposting to a wide range of voluntary & third sector
services.
The key elements of the SPA model include:

Call handling and initial triage –undertaken by skilled and appropriately trained
call handlers who will filter out the simple and less complex clinical journeys at
the point of initial contact. This reduces the handoffs between services which
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ensures quicker access for service users and reduces the time spent by
clinicians trying to direct the service user to the right place.

Clinical navigation – for the more complex patients where relevant clinicians
ensure patients receive the most appropriate care by overseeing their journey
through to discharge. Such clinicians will be able to assess patients, admit into
appropriate assessment centres for further assessment if required and arrange
any longer term care that may be required

Capacity Management – the SPA has a role in coordinating the interfaces with
acute services and social care, and ensures streamlined access into DCHS
services. It also ensures active discharge planning and the management of
appropriate capacity across the health and social care system.
To support the provision of care as close to home as appropriate, integrated
community support teams will be developed across Derbyshire. These teams will
consist of community matrons, community nurses, physiotherapists, occupational
therapists and generic worker roles. They will enable seamless packages of care to
be delivered and easy transfer between disciplines and specialities. Such teams will
be created alongside the emerging CCG based models of integrated community
provision which include the introduction of virtual wards and care coordinators. The
management of activity across these integrated teams will be underpinned by the
further development of the Community Jonah system.
This development will encompass a shift in the focus of care and of the workforce
requirements to deliver this. It will require a workforce that is skilled to be able to
manage care delivery outside the traditional in-patient setting and which has the
confidence to manage the provision of care in a variety of settings.
The use of technology will be a key enabler to these developments, in particular the
use of agile working and mobile health worker technologies. Clinicians will require
fast and efficient access into clinical systems from within the community setting in
order to maximise outcomes and to deliver a quality and safe service. Following a
series of successful pilots, with a range of potential technological solutions,
deployment has commenced in the use of such technologies and further detail is
available from within section 5.10.
5.1.6 Partnerships
As referenced above, the delivery of the service model will be predicated on close
working with CCGs and continued integrated working with social care colleagues in
DCC. The adult service model builds on the existing joint service models for
intermediate care. DCHS will therefore continue to support the implementation of
their specialist community care centre and extra care housing model which will
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encompass a range of care options including intermediate and reablement beds and
day services.
This will be underpinned by close working between the integrated community teams
and social care to ensure that people are supported and wherever possible treated
within their own homes and that urgent and emergency admissions to hospitals are
significantly reduced. Also during the last two years we have, through agreement
with the CCGs, established “Winter Wards” at several sites to respond to their
request for additional capacity. In future years we will respond to such requests by
opening additional beds on several wards across our community hospitals. This will
provide a more flexible response over an increased number of sites which will avoid
the need to set up additional wards that can be costly in terms of recruitment & set up
costs. Using existing wards will mitigate these costs and pressures, and provide
improved value for money.
Further work is also being undertaken with Acute, Primary and Third Sector
colleagues to ensure the correct system & capacity to manage and respond to
changing clinical demands is in place. This model is being developed and provided in
close partnership with these partners and will include generic support roles which will
be promoted to support care across the health and social care interface.
Older People’s Mental Health (OPMH)
5.2
Our OPMH service provides specialist dementia care both in the community, through
our day hospital infrastructure, and in our specialist dementia care wards. Both
elements of our service operate across an integrated care pathway which involves a
number of stakeholders including our local mental health trust, our acute hospital, our
local authority care services, and the voluntary sector.
Our current specialist dementia provision consists of:




Inpatient specialist dementia beds based in the High Peak and Dales through
a 12 bed ward (Spencer Ward) at the Cavendish Hospital in Buxton;
An 18 bed specialist dementia ward (Riverside Ward) and co-located Day
Hospital at Newholme Hospital in Bakewell;
Specialist inpatient dementia services through dedicated wards at Walton
Hospital (Melbourne and Linacre wards) which have 24 beds each, and
Leahurst Day Hospital, which is co-located with the wards;
A specialist Live Well with Dementia Day Hospital at Moorfield which supports
the Chesterfield and North East Derbyshire area.
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The services deliver assessment, treatment and interventions across a range of
acuity in dementia for people who are experiencing a step change in their health
circumstances which leads to a need for more specialised and focussed input.
We recognise, and have responded to, the changes in the population we serve,
which also means delivering services which wrap around the individual and are
integrated. In our general medical health wards, in response to the demand of
comorbid mental and physical health needs, we provide support through specialist
inreach which is led by mental health nurses. In our community services, these
specialist dementia nurses also provide training and development to enhance the
skills and awareness of non-mental health clinicians, underpinned by the framework
of the national dementia CQUIN.
Responding to the fundamental shift towards care that is coordinated around the full
range of an individual’s needs, and the development of integrated, collaborative
working, we have reviewed our overall approach to the delivery and future
development of dementia services as an organisation.
Central to our service developments has been a refreshed look at our inpatient
activity and demand across our localities, an assessment of clinical and operational
synergies between our specialist dementia services, and the other general health
services we provide as a community facing organisation and modelling future
responses to the suggested increase of dementia diagnosis, and its impact.
Core to our approach is the principle of the delivery of dementia services as an
integrated element of our developing community support teams, reflecting the
particular value of continuity of care for people with complex comorbidities, and the
need to engage and integrate more fully with primary care delivery.
We have redesigned our inpatient services to slightly reduce the number of inpatient
beds we offer, in response to capacity and demand modelling, and our commitment
to shifting the curve from high cost, bed-based care to community-focussed,
integrated care delivered in, or as close as possible to, the home.
In reviewing our inpatient service delivery model we have reviewed the skill mix
required to ensure that patients receive a service in the least restrictive, most
community facing alternative, and, as part of our service development will be
developing our discharge liaison role.
DCHS will continue to work in collaboration and partnership with Hardwick CCG, the
lead commissioner for OPMH services within the county, and the other stakeholders
and potential partners in the development and co-production of a fully integrated
dementia care pathway for the patients of Derbyshire.
To achieve this DCHS proposes to –
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
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
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

5.3
Develop an in-reach assessment and support model which provides support to
care homes through liaison and active care planning support, with a view to
reducing unnecessary hospital admissions;
Provide a similar function and integrated delivery model to support the
dementia beds within the local authorities new Community Care Centres;
Rationalise inpatient beds across our 3 sites;
Review opportunities to deliver a step down service, in support of promoting
effective and timely discharge from hospital;
Further enhance our community presence through working in collaboration
with the voluntary sector to support people to live well with dementia;
Further enhance our delivery of wraparound, responsive, specialist dementia
input to our general hospital;
Further develop the dementia care function into our community services
through ongoing co-design and development of the community support team
model including rapid response, development of our workforce, and building
best practice into every component of care.
Learning Disability
The current DCHS Learning Disability portfolio encompasses specialist inpatient,
outpatient and therapy services on the Ash Green site, short stay/respite across 4
core units, a ward at Ashgreen and a range of community based services. All these
serve the community of North Derbyshire.
People with learning disabilities, especially those with severe disability and most
complex needs are some of the most vulnerable people living in our Derbyshire
communities. The aim of national policy for learning disability is to reduce health
inequalities and secure social inclusion and community integration by delivering
person centred care, particularly for those people with complex and multiple
additional needs. This policy has resulted in a reduction of bed based services to one
of specialist community teams and the promotion of improved integration in
mainstream health services. This has been reflected in our service provision in north
Derbyshire, not least through the robust implementation of Healthcare for All.
The continued case for change is strengthened by the national learning disability
strategy, ‘Valuing People Now’, which has the desired outcomes for people with
learning Disability:

Securing improvements in the lives of all

All to have personalised, high-quality support and care plans.
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
Healthcare in communities, in hospitals and in specialist services to be
improved.

More people to be able to live in their own homes or in their locality.

More people have jobs.

The needs of people with the most complex needs to be met in creative and
personalised ways.
Within the DCHS model for LD services a similar approach to that for Frail Elderly
patients will continue to be developed, moving away from bed-based facilities and
developing a range of community and outreach services which shift the focus of care
into the community. Moving from a traditional bed based services to enhanced
community based services will support wider service integration for people with a
learning disability and deliver improved outcomes.
The DCHS model for learning disability sees a stepped approach to services
encompassing a range of treatment and prevention methods. Services will be tailored
to meet the needs of the person and their family and will wrap around an individual to
maximise early interventions and prevent admission. This model will use the least
intensive and intrusive intervention that is likely to be effective with the minimum
disruption to the lives of the patient and their family or carer. As such the DCHS
community teams will provide community based assessment, treatment and support
within a multi-disciplinary framework in the least restrictive environment in the home
or as close to the home as possible.
This approach, illustrated in figure 5-2 below is based on a multi-agency specialist
assessment and a 4 tiered approach to provision that will support access to
mainstream health and social care services with specialist learning disability input
where clinically indicated. The provision of short break respite services are currently
being reviewed by Hardwick CCG as the lead LD commissioner and with DCC with
whom we will work closely to implement the preferred service model, and consolidate
provision.
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Figure 5-4 - Learning Disability Service Model
This is a 4-step model:
Step 1 – Mainstream Primary and Secondary Care Services
Service users will be managed in mainstream services wherever appropriate to
ensure existing relationships with providers are maintained and to minimise
disruption to their lives as far as possible. Access will be supported by specialist
learning disability teams when required.
Step 2 – Specialist Community Teams
Where more specialist input is required, people with a learning disability will receive
specialist assessment and support from the multi-disciplinary learning disability
community teams. This team will be able to provide a range of treatment and
prevention methods that can be tailored to meet the specific client needs to help
them remain at home.
Step 3 – Outreach Intensive Support
Where someone's condition deteriorates or they require urgent support to help them
stay at home this will be provided by a 24 hour outreach intensive support team who
will help to manage situations that might otherwise result in an acute admission. This
team will be able to provide a range of treatment and prevention methods that can be
tailored to meet the specific needs of the client at any time.
Step 4 –In-patient Intensive Support
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Where a person’s needs are so intense or complex that it is not appropriate or safe to
support them in the community then there is provision to admit them to specialist
(acute) LD inpatient services for assessment and treatment. They can be admitted
informally or admitted under a section of the Mental Health Act 1983 if required.
The primary focus of the LD service is to promote health and independence and the
focus of the new service model will be to support people to live in their own homes
and communities wherever possible accessing mainstream services with the support
of specialist advice and treatment wherever necessary. We have implemented
Healthcare for All across all adult services within DCHS to ensure the learning
disability model is integrated with other pathways. The DCHS LD services already
promote rapid access to specialist assessment, treatment, advice and support.
These arrangements will be enhanced within the new model with a more streamlined
approach to access.
The specialist inpatient services will provide an intensive resource augmented by the
community teams to ensure a patient does not stay in hospital any longer than
required. This approach will support a reduced length of inpatient stay and will put
people at the centre of the assessment of their own needs and give them real choice
about how those needs are met through person centred planning.
To support the changes, a Learning Disability Transformational Board led by
Hardwick CCG will oversee the delivery of a transformational change programme
which will encompasses the whole spectrum of health and social care learning
disability services including short breaks and specialist provision.
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5.4
Health, Wellbeing and Inclusion
During 13/ 14 commissioners served notice on several services within this division
due to the change in commissioning organisations and the need to deliver services in
new ways to ensure cost effectiveness. This has impacted on the division in terms of
responding to tenders for services. So far, the division has been successful in
winning five out of five tenders. The newly tendered services are:





Universal Breast Feeding Support services
The Falls service in collaboration with Age UK
Health check service in Bolsover
Diabetes Education
Living with Long Term Conditions ( contract extended )
In 2014/15, we will be using the learning from these successes to inform how we
approach the next set of tenders.
5.4.1 Children’s
5.4.1.1 Services Included
 Health Visiting
 School Nursing


Breast Feeding Support Service
Family Nurse Partnership
5.4.1.2 Case for Change
The national Health Visitor Implementation Plan continues to be successfully
achieved with the anticipated outcome being that by March 2015 DCHS will have
146.5, whole time equivalent, qualified Health Visitors.
Commissioning for Health Visiting services as from October 2015 will transfer from
NHS England to Derbyshire County Council. It is clear that the model needs to be
driven by local need and deliver local outcomes. The commissioners from the
County and City councils, and 4 CCG’s, are working together to co-design an
integrated service specification which will lead to a future integrated service.
Alongside national policy drivers there is also focus on this service from the
Children’s Trust Board which involves the clinical commissioning groups but is led by
DCC and redesign work has been undertaken in collaboration by the multi-agency
teams and with local authority services. The focus for all children’s services within
Derbyshire is the development and future commissioning of a 0 to 19 years care
pathway and DCHS is working to develop service plans to be ready for the new
service specification and tender process.
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Commissioners are also discussing the potential for commissioning a service for a
programme of immunisation and vaccination for all the school age population which
is likely to be procured as an individual service.
The five domains of the NHS outcomes framework have been a primary driver in the
development of the service model, in particular:
Domain1:
 Ensure that families and carers have the relevant information and knowledge
to make health promoting choices regarding their and their family’s lifestyles,
reducing the risks of premature deaths.
Domain 2:
 Universal service provision enables the early identification of Children and
Young people with problems to ensure that they are supported and get the
relevant support and education to equip them to manage long term conditions
and also that families are also supported to be able to deal with such
conditions themselves
Domain 3:
 Movement between the tiers of service provision will enable children, young
people and their carers and families to get support, help and protection during
periods of ill health or injury, which may affect their ability to parent, learn or
reach their long term health potential.
Domain 4:
 Provision is generally about enabling and empowerment which assists service
users to reach their health potential enabling them to go onto reach their life
potential.
Domain 5:
 Treating and caring for people in a safe environment and protecting them from
avoidable harm – assessment of parenting skills and support when issues
arise, monitoring of safe home environments and safe behaviours.
As identified within the demographic analysis within section 4 the age profile for 0-5
and 6-18 year old population is expected to have only minor fluctuations and overall
net change between 2011 and 2017 is a negligible increase. Therefore it is
anticipated that demand for the service overall is expected to remain stable in terms
of new births within the County. However, the development of the national strategies
provides a requirement for all health visitors to see 95 % all parents antenatally by
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the end of March 2015, DCHS has, over the last 12 months, increased the number of
antenatal visits undertaken to 72.42% in April 2014.
DCHS were successful in being awarded the contract for the universal Breast
Feeding Support Service throughout Derbyshire including Glossopdale, this service
was previously targeted but from April 1st 2014 has become universal and DCHS is
ensuring this service is offered at the antenatal visit in order to help parents consider
breast feeding as the favoured option. In February 2014 after an extensive
assessment DCHS was awarded UNICEF full accreditation in relation to breast
feeding.
5.4.1.3 Creating Integrated Service and Pathway Provision
Within children’s services, integration between services and agencies can provide
benefits to the families which they serve and also to the organisations themselves
The multi-agency teams (MATs) will work across three different levels of need,
providing targeted support to families and ensuring that the right professional is
available to meet these needs
The diagram below demonstrates how the multi-agency integrated working will come
together across these three levels:
Figure 5-5 - Children's Service Integrated Working Model
As part of the Healthy Child Programme all contacts identified within it need to be
undertaken by a qualified Health Visitor up to the 2.5 year old assessment To deliver
on the national requirement to meet prescribed levels of Health visitors & qualified
school nurses the emphasis has changed with the increase in qualified Health
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Visitors, DCHS will be commissioned for an additional 5, whole time equivalent,
health visitors during the financial year of 14/15. The tiered model indicates elements
of the service which will be provided in partnership with other agencies, principally
Derbyshire County Council (DCC). Some of these services apply to all children
(universal) and some such as Probation only to targeted groups of children
(targeted). Finally, some services will be linked together to support complex cases
and will be involved as part of the multi-agency team (MAT).
5.4.1.4 Provide Care as Close to Home as Appropriate
In line with the overall DCHS move away from fixed estate, the service is now aligned
to be coterminous with the DCC Children and Younger Adults geographies, and an
agile working culture is being adopted. This has been facilitated by the full
implementation of the TPP patient administration system and the phased
implementation of mobile working solutions.
5.4.2 Specialist Services
5.4.2.1 Services Included

 Health Promotion
 Health Psychology



Contraception & Sexual Health
Chlamydia Screening Office
5.4.2.2 Case for Change
The new commissioning arrangements are now in place as follows:
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
Both Sexual Health services and Health Promotion services are now
commissioned by the Public Health departments sitting within Derbyshire
County and Derby City Council
During 2014 DCHS has been able to develop good provider / commissioner
relationships with these new commissioners and have been very active in the various
commissioner led consultation processes and events, taking every opportunity to
positively influence future service specifications when possible
Specialist services are seeing increasing levels of competition, particularly from
private providers where barriers to entry are low however there has also been an
increasing level of business development opportunities available such as delivery of
speech and language into schools and therefore service models needed to be
developed to support this.
5.4.2.3 Contraception and Sexual Health
During 2013/14 DCHS have delivered an Integrated Sexual Health Services model
bringing together Contraception & Sexual Health (C&SH) service for the North, South
and City together with the Sexual Health Programme from Health Promotion and the
Chlamydia Screening Office in order to promote improved service efficiencies and
responsiveness. During 14/ 15 the commissioners will be tendering for an integrated
service which includes all of the service elements above but also Genito-Urinary
Medicine (GUM). Throughout Derbyshire there are currently 3 providers of GUM
services and DCHS is currently developing formal partnership with these providers to
respond to the forthcoming integrated tender. DCHS will be going into this process as
Lead Provider.
Nurse led services continue to be implemented where appropriate and opportunities
for the development of specialist nurses roles in areas such as vasectomy are being
considered. This will result in some of the more complex issues being clinically
managed by the medical staff but with an increase in nurse led clinics to improve
access.
Currently a great deal of work is being undertaken in relation to demand
management and capacity in order to improve the services delivered to service users
especially in the area of waiting times.
5.4.2.4 Health Promotion Services:
Throughout 13/ 14 work was undertaken to develop a model of delivery for health
promotion services which was in line with commissioning intentions for an Integrated
Healthy Lifestyle service.
The new service model will comprise of four tiers.
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DCHS Wellbeing Model – Overview
DCHS has developed a service model in line with the intelligence gathered, the
impact of this will be a considerable shift in workforce, requiring significant numbers
of more generic staff to be recruited, trained and initially supervised. In addition there
will be a loss of some senior experienced staff, who were delivering the specialised
aspects of the service (e.g. band 6 specialist stop smoking advisors).
It is therefore essential that the transitional phase is managed effectively. Changes to
the smoking cessation service and locality management structure will have been
transacted prior to the transition to the whole Wellbeing Model, in order to support
performance improvement. In addition to the structure below it is intended to recruit 5
transitional advisors/trainers to support the delivery and transition of the smoking
cessation service in the interim transition period.
DCHS currently intends to tender for the Primary Contractor delivering an overall
management of all services (some of those will be accredited providers e.g. GP’s and
pharmacists), provider of specialist services in tier 3 and also as a provider of tier 2 in
areas of significant inequality. This model will be based on the health trainer model
and real community working.
5.4.2.5 Health Psychology
Health Psychology is proposing to undertake a pilot with Community Matron’s to
evaluate the potential benefits from the provision of specialist health psychology
service support to patients who are on, or who could potentially be admitted to,
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community matron caseloads. This project would help establish whether such service
access is helpful in achieving these goals; thereby releasing wider QUIPP savings
and showing a positive return on investment, which would enable its wider
applications as a service development.
In addition to the pilot with Community Matrons, Health Psychology are also
intending to undertake a pilot as part of the virtual ward project based at Staffa
Health. The aim of the pilot is to reduce emergency admissions costs and primary
care consultations for patients who are identified to be of high risk of re-admission by
providing Health Psychology Service input.
5.4.2.6 Ensuring all Services Promote Health and Independence
Health promotion will be a key element of all contacts within all of DCHS services,
particularly with the introduction of the ‘Making Every Contact Count. DCHS is clear
that all services have a role to play in this, regardless of profession or role.
To support this on-going development the key focus of the Health Promotion will be
to support all the services provided across DCHS such that they are able to deliver
health promoting care and support to all service users and their families. The
programmes remaining in this area will be part of the new integrated Healthy
Lifestyles service. The bespoke Training Unit – ‘Training for Health’ will also be
strengthened by expanding & developing other clinical training programmes. This
also makes a contribution towards income generation and will continue to explore
new opportunities in this area.
5.5
Planned Care
5.5.1 Services Include:



Day Case Surgery
Consultant Outpatients
Outpatient Physiotherapy,
Occupational Therapy,
Musculo-skeletal Service (MSK)

Wheelchair Services & Integrated
Community Equipment Services
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




Community Podiatry
Podiatric Surgery
Health Records
Speech and Language
Dental
5.5.2 Case for Change
The planned care services within DCHS operate within an environment of
fluctuating demand and increasing competition. Although planned care has a
number of areas for opportunity to grow, the approach must balance
opportunity with minimising financial risk to the organisation.
Our Planned Care strategy has four key strands:




Target commissioned growth where appropriate to do so
Targeted efficiencies across Planned Care & Outpatients
Evaluation and continued implementation of ICATS service model
Continue to monitor and improve the Quality of Services
Key risks to the services are;
 Introduction of new models of commissioning - posing a risk to activity
and income;
 Increasing competition in the market place with private and third sector
providers moving into DCHS market segments;
 Reduced levels of funding available – commissioners may look to
reducing levels of activity commissioned;
New commissioning arrangements are also in place for Dental Services, which are
now commissioned via the NHS England Local Area Teams. This section sets out
our plan to address these issues and seize the opportunities of an increasingly
competitive market place
5.5.3 Access to services & Clinical Navigation
The Service Model for Planned Care and Outpatients is summarised in the diagram
below. It has been designed to ensure that patients are efficiently and effectively
clinically navigated through the service, providing evidence-based pathways
commensurate to level of need.
The advent of new technologies provides opportunities to review the design and
possibilities for a single point of access (SPA). During 2014 /15 there are plans to
review these opportunities in partnership with patients and service users to inform its
further development.
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Figure 5-6 - Planned Care Clinical Model
5.5.4 Provide Care as Close to Home as Appropriate
Our services are delivered from a range of local settings, providing easy access, care
closer to home and choice for patients. This ensures patients are directed to the most
appropriate facility to meet their individual needs
Three centres currently exist across Derbyshire where there is access to a range of
diagnostic and theatre facilities. These are at Ilkeston, Buxton and Clay Cross
Hospitals. The location and development of theatre facilities will be reviewed, to
ensure delivery of a locally accessible and efficient service model
The division has identified some key specialities where services should be developed
in the community setting in order to promote care closer to home. The division will
target specialities where whole pathways of care can be delivered within the
community setting. Planned Care and Outpatients will continue to work with key
stakeholders to implement these plans as per the strategy of pursuing commissioned
growth.
The Community Podiatry Service will continue to work with Commissioners to review
the provision of services in the Care Home setting. We will work with our partners to
respond collaboratively to the South Derbyshire CCG diabetes care pathway tender.
5.5.5 Creating Integrated Service and Pathway Provision
Planned Care and Out Patients offers a wide range of services delivered by
multidisciplinary teams. Development of the clinical model will promote an integrated
approach to care and ensure that all patients are individually assessed, to determine
care packages which best meet their needs.
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The Division will continue to develop services, ensuring that as much of the care
pathway as possible can be delivered locally. This will reduce the need for referral
onwards to secondary care.
The services will continue to collaborate with other providers of care, to ensure that,
where patients cannot be managed within DCHS, the pathways remain efficient and
seamless across boundaries.
5.5.6 Ensuring all Services Promote Health and Independence
The service model promotes self-management underpinned by shared decision
making to ensure that patients are encouraged to take more responsibility for their
care and optimisation of their health.
Supporting self-care for patients includes signposting them to the range of health
services available to them, e.g. weight management services, and to the full range of
information, advice, education and support services available in line with the “Making
Every Contact Count” initiative.
5.5.7 Ensuring Care is Efficient and Effective
Our Planned Care innovation plans include:









Electronic Patient Record (EPR) in physiotherapy
Evaluating the outcome of texting reminders pilot and application for other
services
Review of technology to further develop SPA
Progressing digital dictation
Evaluation of ORMIS to further identify opportunities and realisation of benefits
Encouraging use of E-Learning
Utilise check in/out screens to streamline patient information collation
Mobile working (tough books/tablets)
Lean Six Sigma in Wheelchair service
Our Wheelchair Services will be developed in a number of ways:



Lean 6 Sigma methodology will be applied to review the service
We will work with Commissioners to review existing access criteria and
demand management strategies
We will develop activity and performance measures within the organisation’s
Business Intelligence System
Our service plans beyond 2016 will be informed by our work with service users and
our discussions with key stakeholders.
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Developments beyond 2016 will continue to be underpinned by the four strategic
principles:
 Target commissioned growth where appropriate to do so
 Targeted efficiencies across Planned Care & Outpatients
 Evaluation and continued implementation of ICATS service model
 Continue to monitor and improve the Quality of Services
Due to the competitive nature of the market and risks highlighted earlier regarding
potential changes in commissioning models the service understands that listening to
the voice of the customer and continuing to provide innovative solutions to high
demand for services in key in its sustained success.
5.5.8 Dental Services
The DCHS dental strategy is based on the following planning assumptions:





Tooth decay is the single most prevalent disease in childhood and is
preventable. Poor oral health leads to pain and infection leading to problems
with nutrition growth, school attendance and speech.
Deprivation and BME groups are associated with higher incidence of dental
disease in children. 36% of Leicester City residents and approximately 15% of
Derby City residents are of BME origin.
Derby City and Leicester City perform poorly for children's oral health, the
former being third worst in the East Midlands region in 2008, and the latter has
the highest level of disease.
An increasing number of children with severe disabilities are reaching
adulthood. This places a strain on service delivery because their treatment
pathway is more complex and often requires an MDT approach.
Oral disease patterns and patient expectations have altered over the last 30
years. The number of people losing all their teeth is falling and therefore the
number retaining teeth that need repair and maintenance has increased.
All dental commissioners have now moved into the NHS England Local Area Teams.
Currently the national Dental Contracts are being reviewed and decisions are
awaited regarding the re-commissioning of Specialist Care Dental Services as well as
high street dentists. In this regard it is anticipated that Out of Hours dental services
may be commissioned separately to special care services in the future and this will
impact on DCHS’s current provision. Confirmation of this is awaited and the DCHS
plans for the future consolidation of out of hours services across the county have
been put on hold until the outcome is known.
Overall consolidation of the locations from which Dental services are provided in
Derbyshire has now been completed, whilst within Leicestershire the public
consultation regarding our proposals has been undertaken and the implementation is
being pursued. Both Derbyshire and Leicestershire services are in the process of
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appointing Specialist Care Registrars which are essential requirements for the
provision Special Care dental services.
The serious challenges continue in relation to the delivery of the GA 18 week referral
to treatment time and additional non-recurrent funding has now been secured to
address this once the capacity for increased sessions within the acute setting has
been identified. It is planned that the additional activity through 14/15 will address
the current capacity issue.
5.5.9 Speech and Language Therapy
The DCHS Speech and Language Therapy strategy is predicated on the following
Planning assumptions.
For Children:
 Stable incidence of speech/ language disorder (in the context of rising rates of
speech/ language developmental delay)
 The continuing policy for children with additional learning needs to be met in
mainstream education settings.
 Universal speech, language and communication needs (which all children
need) will be met by the wider children’s workforce (in DCHS, DHFT, CRHFT,
schools and early years settings)
 Targeted speech, language and communication needs (that many children
need e.g. those with delayed language development) will be met by the wider
children’s workforce (in DCHS, DHFT, CRHFT, schools and early years
settings)
 That Derby City Council and partners will adopt the SLCN integrated strategy
that is in place in Derbyshire.
For Adults:
 The increasing awareness of dysphagia and associated risks in primary care.
 There is a continuing expectation of self-care.
 That on-going funding for the training for Care Home staff by Dysphagia
trained nurses will be provided which will enable the early identification and
access to care for people with dysphagia.
Generally
 There is an increasing expectation that high tech solutions will be made
available to those with communication difficulties.
A new clinical model focussed on specialist care is being implemented with an
increased number of contacts provided on an outpatient basis and with stricter
access criteria for children's SLT. This is increasing productivity, but the service is
still unable to meet the demand in the adult service which has gone up by as much
as 22%. In response to this a business plan has been developed and submitted to
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commissioners which will, if agreed, identify additional funding to extend capacity
especially in the adult dysphagia service. In the meantime the adoption of new
technologies continues, with Skype consultations being trialled in some of the
services, and the service continues to successfully secure smaller contracts with
individual schools and we anticipate a continuing expansion of this element of the
service portfolio in 14/15.
5.6
Support Services
Services include:




Administration and Record Management
Facilities Management
Corporate Services
IM&T Telecommunications
The Operational Efficiency Programme (OEP)16 identified £8bn of possible
efficiencies within Support Service functions across the whole of the public
sector. This equates to savings of between 20% and 30% of total spend on
Support service functions.
DCHS has already demonstrated improved value for money, by actively reducing
inefficiencies, including duplication, within support services and non-clinical support
functions without reducing the quality of the services delivered. It will continue to do
this through the wider adoption of new technology, process redesign and the adoption
of a shared service approach.
The continuing challenges in delivering effective and efficient Corporate and Support
service functions across DCHS include;



16
Fragmentation – as DCHS has multi-sites with a large number of functions,
many of which have their own Corporate Support service operations and
processes and which it is intended will be rationalised as the Estate is
reduced.
Information – management information on the investment in Corporate
Support service functions will be reviewed to identify accurate costs and to
establish trends and comparisons which will enable efficiencies
–Lack of standardisation – higher costs result from the lack of
standardisation, simplification and sharing of Corporate Support service
functions. A full review of integrated facilities arrangements and
administration services will be undertaken to overcome this issue.
published by HM Treasury in May 2009
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All the DCHS Service Divisions and Corporate Functions have reviewed their
efficiency and built improvements into their own plans. The remaining challenge is to
identify innovative ways of working utilising existing and new technology as well as
process and workflow redesign across the organisation.
The support services, particularly Administration and Record management will
underpin and support the development of the SPA principle and the associated
processes across DCHS services. This will support centralisation and the adoption of
best practice on a consistent basis across the organisation.
Transforming Support services, particularly facilities management will not only be
supported by the DCHS Estates Strategy but will also contribute to the planning of
the latter. Work needs to be undertaken as a priority within the overall Estates
Management to;
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
Review and optimise utilisation of buildings
Introduce a logistics service
Multi-skill facilities and estates staff
Enable fewer staff to perform a wider number of roles
The Exploitation of technology will be the key driver for delivering transformation to
support services. These will minimise paper transactions, facilitates the flow of
information and improves data collection, thus increasing efficiencies and eliminating
errors.
There are a number of benefits that can be realised through greater use of
technology. These include:




Improvements in the quality of service experienced by clients
Reduced headcount, with consequent savings
A more consistent and uniform approach to business processes through
automation of standard process flows
Rapid turnaround of transactions requiring approval and/or exception handling
(workflow).
There is a broad range of technological solutions which it is proposed to implement to
underpin this:

Complete roll out of E-rostering, which provides a way of controlling workforce
costs
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

Digital imaging which facilitates document movement in and out of the
organisation
Workflow - a process tool which delivers the right work to the right people at
the right time
The review of the efficiency of supporting functions includes all the corporate
services which are undergoing detailed scrutiny to ensure that they lean and fit for
purpose within the context of this plan. This will also include the review and
rationalisation of the current payroll and financial ledger system supplied through
SBS and the system support received through Nottinghamshire Healthcare NHS
Trust. We will also explore with partner organisations the benefits of sharing back
office functions to drive efficiencies.
It is the intention that all the facilities provided to support the new service models
should be fit for purpose and as such they should promote the optimal patient and
user outcomes. All support services and systems will be designed to facilitate
productive ways of working and the delivery of effective clinical services
In considering how best to optimise management resource, we have focused on:




5.7
Reducing unnecessary spend on Support service functions in order to free up
as much resource as possible for CIP savings and reinvestment in frontline
services.
Maintaining the capacity and capability to continue to deliver high quality
services and support the delivery of the new service models.
Improvements in the quality of service experienced by Patients
A leaner more streamlined organisation that is easy to do business with and
that all Stakeholders can engage with.
Service Development Process
In order to ensure the effective delivery of its organisational goals and objectives
DCHS has actively engaged all services in a continuing discussion about how it will
be organised and how it will deliver services over the next five years. This has
culminated in the development of a Clinical Strategy which underpins the refreshed 5
year plan and the service development and operational delivery plans that will enable
this to be delivered.
This service development planning process has been undertaken over a number of
years with oversight from the DCHS Board and implementation managed through the
individual services with support from the Programme Management Office.
The key principles of this process involved:

Effective leadership from within the services, with support and guidance from
the key corporate and quality leads
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
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
Strategic planning sessions held with key service clinical, business and
managerial staff. These help to gain a clear understanding of what the
strengths, weaknesses, opportunities and threats are for the service;
Monthly ‘Confirm & Challenge’ sessions held with the executive Board
members, the key service clinical, managerial and business leads, along with
corporate and quality leads;
Implementation of a Quality Impact Assessment process which all service
development plans are required to undertake. This ensures that the plans and
their impact upon quality are fully understood and that effective mitigation
plans are in pace to deal with the associated risks. These plans must be
signed off by the DCHS Medical Director and Director of Quality/Chief Nurse.
Involvement of key stakeholders, both internal and external to DCHS,
including clinical commissioning groups and local authority.
The service development strategies outlined within this section set out a significant
programme of change for DCHS services. These changes will involve a significant
number of projects, with complex interdependencies externally and internally.
Therefore DCHS has implemented a Programme Management Office (PMO) in order
to assure and monitor delivery of these projects.
A fundamental element of the PMO process is the Quality Impact Assessment
outlined above which is linked to the quality assurance strategy in section 7. As a
consequence of this process all the plans and underpinning assumptions have been
risk assessed with mitigation plans agreed and essential KPIs in place to monitor
their delivery. As such DCHS is confident that the service development plans outlined
are achievable given the level of service and clinical involvement, and the work
undertaken with external partners to constantly review and challenge these.Error!
Reference source not found. provides a detailed overview of the structure of the
PMO and the way in which it will assure and monitor delivery.
5.7.1 Innovation and Service Improvement
DCHS has an established and committed approach to innovation and continuous
service improvement which is evidenced through a strong track record of delivery.
This approach has provided the basis for our further work in relation to productivity,
efficiency and the pursuit of a CIP programme that ensures that the quality and
effectiveness of our services are not compromised. This work is all set within context
of the national policy directives and the local commissioner priorities all of which align
with DCHS’s strategic objectives and the aspirations expressed within this plan.
DCHS has aligned its service improvement strategy to its organisational priorities and
this covers:

Creating a Culture for Innovation
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

Embedding the Innovation and Service Improvement agenda into our
transformational change projects
Building Improvement Capability and Capacity
The organisation has modelled its innovation culture on the NHS Institute for
Improvement and Innovation approach taking into account the seven dimensions that
are characteristically attributable to successful innovative organisations. This has
included the embedding of a hugely effective Improving Leaders Programme which
has a strong track record of service efficiencies and which is used to develop future
CIP initiatives and to underpin service redesign and wider efficiencies. To
complement this DCHS is also pursuing the use of Productive and Lean techniques,
such as in its planned care services, and has worked extensively with QFI to embed
the Jonah system across its hospitals and community services. This has resulted in
the significant efficiencies covered earlier in section?
5.7.2 Benchmarking and Best Practice
DCHS belongs to the NHS Benchmarking Network and benchmarking and best
practice comparisons have been undertaken to continue to promote efficiencies both
internally, between localities, and externally with other organisations. The outputs
from such comparisons are used to engage the Board in strategic decisions
regarding service developments as well as in routine performance management
reports.
An example of this is the Bed Utilisation review that was undertaken across all the
community hospital beds and which supported the further redesign of patient
pathways. Further comparative work was undertaken with Adults service models
across the Country in relation to the development of the Single Point of Access and
integrated team models within the ICBS division. The services are now engaged in a
review of the Salford Model to see how this can be adopted across DCHS.
Within Health Wellbeing and Inclusion services Deloitte was commissioned to
support redesign work to ensure that the services are well prepared for the
forthcoming tenders. DCHS is also an active member of NHS Elect and also of the
Foundation Trust Network both have which continue to support work around the
pursuit of best practice models. Further work is now in hand to embed a systematic
approach to benchmarking across the service lines and the Planned Care services
will form the initial phase of this work.
5.7.3 Staff Engagement
All of this has been fed into the work with the staff through organisation-wide staff
conversations and engagement events and focused group working around specific
redesign and improvement projects. Already over 300 staff and managers have been
through the Improving Leaders Programme and have been involved in over 60
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improvement projects since its inception. The staff and managers who have been
through this programme, together with the network of Innovation scouts across
DCHS are going to be supported to pursue continuous service improvements in order
that this approach to innovation can be better embedded across the organisation.
The staff forum is a source of energy and innovation and the Service Improvements
and Organisational Development teams will work closely with them to secure their
support. Also within the PMO work is in hand to strengthen staff involvement within
the projects that are intended to deliver the CIP programme and the organisations
objectives for 2014 - 16
5.8
Estate Strategy
5.8.1 Overview
The Estate Strategy 2013 – 2019 will provide a framework for improving the health
and wellbeing of the whole population we serve. This will be achieved by supporting
and adapting to changing service and business needs, ensuring compliance with
statutory and regulatory obligations and policies, maximising the utilisation and useful
life of properties by timely maintenance and protecting the value of assets through
the effective management of the estate.
The main objectives of the strategy are to:









Provide the best environment to support high quality patient care.
Ensure that assets are used efficiently, coherently and strategically to support
DCHS plans, commissioner priorities, identified clinical strategies and models
of care.
Ensure that the operational performance of assets are recorded, monitored,
reviewed and where appropriate improved.
Ensure an effective asset management approach to risk management, service
and business continuity.
Support and facilitate asset planning and management with other
organisations.
Meet Good Corporate Citizen and Carbon Management requirements.
Ensure the strategic disposal of assets not required (including land) as
described in the ‘Protection of Assets’ guidance for National Health Service
Foundation Trusts
Ensure the Trust meets Outcome 10 of the CQC framework, Safety and
Suitability of Premises, and meets the NHS requirement for the NHS to
provide clean and safe premises, which are fit for purpose and kept in
accordance to best practice.
Have a clear and appropriate Communication Strategy which underpins the
delivery of the Estate Strategy.
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5.8.2 Transfer of Assets
The large scale re-structuring of the NHS in April 2013 led to the transfer of NHS
Estate from the PCTs either to NHS Trusts or NHS Property Services. DCHS has
been the recipient of a significant proportion of the estate that is used for the delivery
of clinical services in Derbyshire.
Where DCHS had long term intentions to continue to utilise the estate, uses the
majority of a premise for clinical use and has a majority use, these premises were
permitted to transfer to the Trust, in most other circumstances, the property
transferred to NHS Property Services. This applied to both freehold and leasehold
premises.
DCHS is now fully responsible for maintaining the safety and quality of the estate that
has transferred to it, and for working with other owners/landlords to ensure the safety
and quality of their estate used by DCHS.
5.8.3 Ensuring Quality of the Estate
To ensure that the Estate fits with DCHS’ future plans and to support the overall
planning process a Six Facet survey was commissioned by DCHS to analyse the
existing estate in terms of its condition and performance as a capital asset, including
leased properties. The report will support our ongoing investment programme
detailing capital requirements for the upgrading and refurbishment of existing
buildings and addressing long term viability, backlog maintenance requirements and
statutory requirements issues of owned estate.
The report was published in 2014 and was based on the following;



5.9



Physical Condition;
Quality of Accommodation;
Statutory Compliance;
Energy Efficiency;
Functional Suitability;
Space Utilisation.
IM&T Strategy
Information and Information Technology will be critical in enabling the success of our
service development plans and meeting the challenges of the changing NHS
environment. DCHS’s IM&T Strategy sets out our key strategic intentions over the
period of the IBP. These are:


Contribute to patient safety through the use of high quality and robust
information systems
To maximise the use of the electronic patient record containing the health
information for every patient in our care
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



To facilitate and support genuinely seamless care for patients by linking
information throughout the organisation and the wider health and social care
community, ensuring data is available wherever it is needed
To support our services in delivering efficient services through the use of
technology and information
To provide performance management information that facilitates and supports
decision making, the organisational assurance process and a ‘ward to board’
information culture.
To place emphasis on information systems and technology improving patient
care and supporting innovative solutions to change pathways and support the
organisations service development strategy.
Our current IM&T Strategy has been developed in line with those of the individual
services and divisions to provide specific technology solutions. Our refreshed
strategy for the next 5 years looks to build on the work we have undertaken to date.
Its main areas of focus are set out below:
5.9.1 Unified Clinical System
A unified clinical system, supporting electronic clinical noting will be an essential part
of our IMT Strategy. Such an approach supports integrated working and puts in place
a foundation to deliver high quality, seamless care by providing access to a unified,
patient focussed record to any authorised clinician in any setting. It provides patient
level information through a controlled system which will improve the quality and
security of the information collected. A single clinical system, used at the point of
care will provide centralised, near real time information which will be critical in
meeting the requirements of our commissioners and the governance requirements of
becoming a Foundation Trust.
Our strategy will:




Complete the roll out of TPP SystmOne for all appropriate DCHS community
services
Deploy TPP SystmOne to our Minor Injuries Units
Deploy TPP SystmOne within our inpatient and outpatient services
Increasingly exploit the advantages provided for by unified systems and
records to drive quality and efficiency throughout our services
All of the above deployments will link the clinical records of service users across and
beyond DCHS as well as providing a unified record to better facilitate communication
outside of the TPP SystmOne environment.
5.9.2 Cross Provider Network and System Linkages
The establishment of common, integrated social and clinical care information,
centred on the citizen, is an ongoing ambition to underpin health and care
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community-wide integration and transformation initiatives. It will enable care
professionals to work within and between their respective organisations, supporting
the continuity of care across pathways and to provide the opportunity to support
citizens access their care records so that they may more fully participate in their care.
The health and social care organisations in Derbyshire are at varying levels of digital
maturity and as a consequence are not able to ensure that the various systems in
use at the point of care across Derbyshire are easily and seamlessly able to
exchange the necessary information to support the integration and transformation of
local services.
So as not to inhibit greater service integration, the health and social care
organisations and associated partner agencies in Derbyshire have committed to
implement a platform solution that builds on the value of the capabilities and data
contained within the current best of breed systems to present professionals delivering
care in Derbyshire with a common and universal access, subject to appropriate
governance, to care information from a wide variety of information sources and to
support citizens to access their information. To ensure that the maximum value from
this can be achieved at the earliest possible opportunity, the CCG's within Derbyshire
are seeking support from the Integrated Digital Care Technology Fund for matched
funding to accelerate the scope and pace of this critical initiative.
The delivery of care pathways requires us to have the ability to communicate with
other care providers both within and outside of the NHS. It is critical that we are able
to further develop links between DCHS and other providers. This proposed unified
system for electronic records will provide a platform for such communication.
Our strategy will:



Enhance automatic communication to all GP practices through the generation
of electronic discharge letters and other clinical communication
Work with colleagues in Derbyshire County Council to further enhance our
connectivity with them, through shared networks, to support shared estate and
the appropriate transfer of information for individuals within our care Examine
the potential for wholesale adoption of the NHSmail system thus easing
communication and facilitating patient information exchange with local acute
hospitals and General Practices
Continue to work with colleagues across the health and social care community
to pursue technologies to link community, acute, social and primary care
together.
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5.9.3 Electronic Clinical Records
Electronic clinical records will play a fundamental role in the future of DCHS. They
will allow for the quality assurance of information collected, the sharing of records
within and beyond the boundaries of DCHS and increase information security.
Electronic notes will gradually replace paper notes and their accompanying demand
for storage, handling and transportation.
Our strategy will:


Ensure all DCHS services using TPP SystmOne will, where not already doing
so, move to electronic clinical noting within the system.
Deploy e-prescribing as part of our TPP SystmOne Community Hospitals
deployment.
5.9.4 Mobile Health Workers
The use of technology to support clinicians delivering care in the patients’ home is a
significant requirement within the IBP. Mobile access to records delivers efficiencies
in reducing the need for travel and office space, delivers improved care by providing
the clinician with essential information at the point of care and improves information
security by removing the need to transport paper records.
Our strategy will:


Complete the roll out of the mobile health worker programme across our
services.
Embed the changes to working practices which mobile working brings to
extract maximum benefits from our investment.
5.9.5 Telehealth
The remote monitoring of patients through technology installed in their own homes
allows DCHS to maintain care closer to the patients’ home. Evidence from across
the country also suggests that Telehealth delivers efficiencies in reducing visits to
patients and preventing admissions through early intervention to address
exacerbations in existing conditions.
Our strategy will:


Learn lessons from our current telehealth deployments with a view to
expanding the portfolio of services delivered through telehealth.
Learn lessons from the developing national evidence to guide our future
telehealth deployments
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.
5.9.6 Efficiency Technologies
A range of technologies exist that offer the potential to contribute to the efficient
running of our services and support specific IBP initiatives such as the reduction of
estate. DCHS has recently deployed wireless technologies, Voice Over Internet
Protocol (VOIP), mobile working, e-rostering and room booking systems.
Our strategy will:





Work to deploy specific solutions to support the development of individual
services including patient kiosks, digital dictation and a room contact
centre technologies to streamline access to DCHS services.
Continue the roll out of VOIP across the DCHS estate in line with the
DCHS estates strategy
Will seek to exploit the potential of agile working to support changes in the
DCHS Estate Strategy
Look to deploy presence and communication software to facilitate easier
communication such as teleconferencing across the Trust
Continue to explore the adoption of thin client technologies with a view to
introducing them as a gradual replacement for desktop PCs
5.9.7 Information Exploitation
Being an efficient and effective provider of health care services places a heavy
reliance on capture, analysis and exploitation of information. We will require
information to help us monitor and improve our performance, understand the quality
of our services, ensure that we are meeting our patients needs and to effectively
budget. This information needs to be near real time and analysed and presented in
ways which are easily accessible to staff, service managers and board members
alike.
Our strategy will:



Increase our collection of patient level information through the increased
roll out of electronic clinical information systems.
Increase our focus on the production and use of outcomes and
benchmarking information.
Build on the foundations of the existing business intelligence system to
provide a system which is more comprehensive in its coverage of
information and more widely available to staff
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
establish the our business intelligence system the focal point for all
performance information in the future
Key points of this section:

DCHS has well developed and robust plans in place to ensure it can meet
the challenges of the next five years;

Service developments are planned to address key factors identified from the
environmental analysis, in particular the SWOT and PESTLE analysis;

Supporting financial modelling underpins the service development plans and
assumptions and projections are based on known commissioning intentions
and an analysis of demand and market factors;

Robust plans are in place for services to meet the needs of commissioners,
and service users.

A robust framework is in place to monitor and assure implementation of
plans via the PMO approach.

DCHS has in place robust enabling strategies such as Estate and IM&T to
support the service development plans.
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6
Quality
Purpose of this section:





Describe the DCHS approach to quality in both national and local contexts
Describes taking quality forward the DCHS Way
Outline the elements of the DCHS Quality Governance Framework
Describes the monitoring of performance and quality improvement.
Describe our quality goals and outcomes of success for the future
The DCHS Clinical Strategy has been developed to support the delivery of high
quality and equitable services that meet the needs of people cared for by Derbyshire
Community Health Services (DCHS) NHS Trust. It describes those key clinical
pathways we believe will have the greatest impact on the health of our local
population.
Our clinical strategy will:
 Develop seamless community care focused on the individual needs of our
patients
 Ensure that care for patients is provided at home or as close to a patient’s
home wherever possible
 Facilitate patient (and carers as appropriate) engagement in planning their
own care
 Encourage staff to use their clinical judgement
 Encourage staff to work at the top of their licence to release time to care but
also to improve job satisfaction and encourage career development
 Ensure good clinical leadership and effective management of staff
 Develop fully integrated teams providing care over a 7day working week
 Develop community Jonah to deliver some outcome data as well as process
data
 Roll out of SystmOne/TPP
 Refine the case load weighting tool to more closely match capacity to need
 Only collect data which can be used in a meaningful way
Underpinning our clinical strategy is our quality strategy. Our quality strategy
provides a framework to ensure that quality services are delivered in response to the
specific requirements of our patients and public, our commissioners and our
regulators. It also supports the delivery of the DCHS Integrated Business Plan (IBP)
2014-2019 and the achievement of our vision to be the best provider of local
healthcare and to be a great place to work.
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6.1
How
At DCHS we are building upon firm foundations. We have strengthened our approach
to quality governance as we have progressed our ambition to be an NHS foundation
trust. We are building upon the successful delivery of our annual Quality Accounts,
annual CQC registration and a strong history of delivering against our service
contracts including delivery of our CQUINS (Commissioning for Quality and
Innovation)– where financial incentives are attached to the delivery of stretching
quality indicators.
With our patients and our staff we have set our vision and values and defined our
organisational approach by which our services will be delivered; these are
encompassed within the DCHS Way - Quality Services, Quality People and Quality
Business.
The Board has reviewed the organisation’s governance structures and reaffirmed our
commitment to the delivery of high quality, equitable and sustainable services that
echo the values and aspirations of the communities that we serve. As a result we are
totally committed to the provision of quality services as defined in the Equity and
Excellence: Liberating the NHS17. Our approach to quality utilises three elements;
clinical effectiveness, safety and patient experience, as set out below. This is in the
belief that it will be the combination of all three which assures our stakeholders about
the quality of our services.
At DCHS we define quality as:



6.2
The delivery of services which are focused upon patient safety and reducing
risk which may cause harm.
The delivery of services which are effective in the context of clinical outcomes
and patient related outcomes.
The delivery of services which are considered by our patients, service users,
their carers and families as being a positive or good patient experience.
Quality Services - The National Context
6.2.1 Accountability as a public organisation
Quality service delivery is a core part of NHS care. Our public have a right to expect
services, which are not only free at the point of delivery, but are safe, effective, meet
individual needs and which take their views into account. As an NHS organisation,
DCHS is accountable for the services it delivers. This is in accordance with the
national requirements in terms of policy (via the Department of Health), regulation
(e.g. via the Care Quality Commission – CQC, Monitor etc.) and clinically relevant
17
Equity and Excellence: Liberating the NHS (White Paper) Department of Health July 2010.
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outcomes (as evidenced in accordance with the National Institute for Health and
Clinical Excellence (NICE) and the NHS Outcomes Framework18.
In 2010 the government, via the Department of Health, produced a new White Paper
(Equity and Excellence: Liberating the NHS). This set out the strategic plan for the
NHS which included major structural changes, placed patients at the heart of service
delivery, focused upon outcomes and empowering organisations and professionals to
continually improve quality. Maintaining quality and safety during a period of change
and transition is a priority for providers and commissioners alike. To this effect we will
work with our commissioners (from Primary Care Trusts to Clinical Commissioning
Groups) to maintain quality and safety during this time.
In addition, the annual delivery requirements required of NHS organisations are
reflected within an Annual Operating Framework produced by the Department of
Health.
Our strategy has been developed in the knowledge of the changing commissioning
and regulatory framework within the NHS and the challenging economic and
demographic climate in which public services are operating.
Alongside the above we are reminded of our accountability to our patients and
service users learning from the experiences of other organisations as demonstrated
in the Health Ombudsman report, Care and Compassion19 and the Francis Inquiry 20
plus the former Healthcare Commission report in relation to Mid Staffordshire NHS
Foundation Trust21. 2013 has seen the publication of a plethora of reports about care
and patient safety including the Berwick review22 into patient safety, Keogh Review23
of hospital mortality; Cavendish review24 of the role of healthcare support workers;
Neuberger review25 of end of life care and Ann Clwyd’s26 review of the NHS
complaints system. All of these reports provide us with valuable information based on
the experiences of other health care providers and focus our attention to the
18
NHS Outcomes Framework (2014/15) Department of Health.
Care and Compassion – report of the Health Service Ombudsman on ten investigations into NHS
care of older people. (February 2011), Produced by the Parliamentary and Health Service
Ombudsman.
20 The Mid Staffordshire NHS Foundation Trust – Independent Inquiry chaired by Robert Francis QC
HC375-1 London Stationary office.
21 Investigation into Mid Staffordshire NHS Foundation Trust (March 2009). Healthcare Commission.
22 A promise to learn – a commitment to act Improving the safety of patients in England (August 2013)
Professor Don Berwick
23 Review into the Quality of care provided by 14 hospital trusts in England: overview report(July 2013)
Sir Bruce Keogh
24 The Cavendish review: an Independent review into healthcare assistants and support workers in the
NHS and social care settings(July2013) Camilla Cavendish
25 More Care, Less pathway: a review of the Liverpool Care Pathway (July 2013) Baroness Julia
Neuberger
26 A Review of the NHS Hospitals complaints System – Putting Patients Back in the Picture, Oct 2013
Right Honourable Ann Clwyd MP and Professor Tricia Hart
19
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importance of a positive culture amongst staff. DCHS has reviewed these reports
with care and will build relevant issues into its quality strategy and plans going
forward
6.2.2 National Frameworks and tools – Safety, effectiveness and the patient
experience
A number of nationally defined tools and systems have been developed to support
the delivery of quality services. Examples of these include the National Quality
Board27 (providing guidance in relation to Quality Governance, Early Warning
Systems; staffing levels etc.), NICE28 (in relation to Quality Standards etc.), Monitor29
(setting out a Compliance Regulatory framework), CQC30 (regulation and standards),
NPSA31 patient safety initiatives such as (Safety First Campaign, safety alert and risk
management systems), National Enquiries and National Audit work.
The Chief Nursing Officer (CNO) has led work nationally in relation to Compassion In
Practice: Nursing Midwifery and Care staff; Our Vision and Strategy32. The strategy
sets out the shared purpose for nurses and care staff to deliver high quality,
compassionate care and to achieve excellent health and wellbeing outcomes. It
builds on the values set out within and the pledges and rights of the NHS Constitution
which patients, the public and staff will expect. This will be aligned with the DCHS
Quality Strategy, underpins the work we have undertaken related to the Francis
recommendations and supports our ambition to embed the ‘6C’s’ organisationally
and to recruit and support ‘Care Makers’ across our organisation.
We are committed to effectively implementing the NHS Equality Delivery System
(EDS) which will help us to meet our obligations under the Equality Act 2010 and to
deliver better outcomes for our patients and communities.
Our strategy takes into account all of the above and our governance structures
enable us to ensure we review, adopt and comply with these standards as required.
National Quality Board. Quality Governance in the NHS – A guide for provider boards (2011) and
Review of early warning systems in the NHS (2010).
28 NICE – National Institute for Health and Clinical Excellence. www.nice.org.uk/guidance/quality
standards
29 Monitor – Independent regulator of NHS Foundation Trusts. www.monitor-nhsft.gov.uk
30 Care Quality Commission – Guidance about compliance – regulations, outcomes and judgement
framework. www.cqc.org.uk
31 National Patient Safety Agency. www.npsa.nhs.uk
32 Compassion in practice Nursing Midwifery and Care Staff Our vision and strategy DH Dec 2012
27
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6.3
Quality Services –The Local Context
6.3.1 Quality Initiatives
To date, our work has developed within regional and national initiatives such as
Energising for Excellence (E4E), the QIPP (Quality, Innovation, Productivity and
Prevention) Safe programmes of care and through the development of Regional and
Local CQUIN targets (i.e. commissioning for quality).
Safety Express33 is the name of the QIPP Safe Care workstream which focuses upon
a reduction in ‘harm’ to patients in relation to pressure ulcers, falls, urinary tract
infections (associated with urinary catheters) and Venous Thromboembolism (VTE).
It sits within the E4E and High Impact Intervention programmes of work. This work
combines the identification of harm to patients, baseline audits, service improvement
methods, clinical benchmarking and measurement of the patient experience on a
regional and national basis.
We have continued to enhance our quality reporting at board level, linked our board
members to frontline services in our programme of ‘Quality and Safety ‘Board Visits’
and developed our staff engagement and leadership strategies. We have developed
a quality improvement and assurance framework to ensure connectivity between our
board; our widely distributed workforce and our patients, wherever they may be cared
for. The use of patient stories feature throughout our organisation, ensuring that
lessons learned from patients’ experience drives service improvement processes and
quality care is kept at the centre of decision making.
6.3.2 The DCHS Way
We know from our patients and the public that they want to be listened to and to be
involved in their care. We also know that people wish to be treated with fairness,
dignity and respect and by staff who demonstrate compassion. To this end we have
developed our patient engagement and experience strategy to guide our work with
our patients, their carers and families and the wider public.
As an organisation we are committed to a sustained focus upon quality improvement,
structured around the three domains of patient safety, clinical effectiveness and the
patient experience.
Our strategic aims, culture and values have been developed in partnership with our
staff and the ‘DCHS Way’ is the mechanism by which we deliver Quality Services,
within a Quality Business, by our Quality People. The DCHS Way is about our vision,
our ambitions, our objectives and the cultures and values we have as an
Safety Express – the department of Health QIPP Safe Care work stream.
www.patientsafetyfirst.nhs.uk
33
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organisation. We have reviewed our governance and leadership structures to ensure
that they are fit for purpose, that they are aligned to both the DCHS Way and to
provide a robust accountability and assurance structure. This ensures a ‘frontline to
board’ process as the Board, Directors, Governors and membership and our staff
work together in the delivery of Quality Services.
6.4
The Quality Journey – ‘THE DCHS WAY’
6.4.1 Moving Forward
At DCHS we are committed to a journey of continuous quality improvement. This is
based on a firm foundation upon which to build, an ongoing commitment as a
learning organisation, and an aim to continually improve our services.
We do not underestimate the challenge we are facing. Our organisational service
plans (IBP) set out our ambitions as well as the service and financial challenges
which lie ahead. Delivering our workforce plans will be challenging, however delivery
of Quality Services by our Quality People and Quality Business structures will enable
us to deliver our IBP.
This strategy will support us on our journey from NHS Trust through to NHS
Foundation Trust. Annual plans will support the delivery of the strategy. These will be
revised and updated within a risk based approach continually responding to a
changing NHS, regulatory requirements, the health needs of and views of our
population, Foundation Trust Membership, Governors and staff.
6.4.2 Building upon firm foundations
Our legacy of Quality Service delivery has already been referred to including a
history of CQC compliance, delivery of Quality Accounts34, and the adoption of safety
initiatives such as Safety Express. In addition we have reviewed our quality
performance reporting to the Trust Board, our governance structure and our risk and
assurance processes. We continually focus upon our abilities and capabilities as
leaders, and the quest for service improvement. Our Board Assurance Framework
(BAF) has been revised in order to reflect the key organisational risks including those
which may impact upon the delivery of Quality Services. Our staff are a key asset in
the delivery of quality improvement. The development of our people and
organisational effectiveness strategy is a further step in this process.
34
Quality Account - A Quality Account is a report about the quality of services provided by an NHS
healthcare service. The report is published annually by each NHS healthcare provider and available to
the public.
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6.4.3 Review of Quality Service Governance
This has been based upon best practice, national guidance and the need to meet
regulatory requirements (including Monitor, Care Quality Commission, National
Quality Board, and learning from other organisations). As part of this process we
have looked at the capabilities and abilities of our Board members, reviewed our
Board Committee structure to strengthen our assurance processes and continue to
embed the DCHS Way which underpins the culture and values of the organisation.
Performance monitoring and quality improvement has been strengthened alongside
our reporting and assurance processes with quality performance being focused upon
combining quality services, patient related outcomes and the patient experience.
This strategy provides a framework in which to embed quality improvement across
the organisation which combines Quality Assessment (the data), Quality
Improvement (Actions) and Quality Assurance (systems which provide assurance). A
‘golden thread’ performance framework will align strategies so that employees know:
what they should be doing, how they should be doing it and how this fits with the
organisations overall vision.
Page | 117
THE DCHS QUALITY GOVERNANCE FRAMEWORK
 DCHS Quality Strategy
 DCHS Integrated Business
Plan
 DCHS Workforce Strategy
 DCHS Public & Patient
Involvement & Engagement
Strategy
 DCHS Way
 DCHS Equality, Inclusion
and Human Rights Strategy
 Quality improvement and
assurance framework
STRATEGY
PROCESS &
STRUCTURE
 Board Leadership
 Organisation & Individual
Roles & Accountability
 DCHS way & ‘golden
thread’
 Review of Capabilities
 Learning Organisation
 DCHS way
 Pulse check
CAPABILITIES &
CULTURE
DCHS Quality Governance
Framework
MEASUREMENT
 Quality Governance Structure
Committee & Subcommittees
 Board Assurance Framework
 Foundation Trust Governance
Structure
 Divisional & Service Quality
Structure
 Frontline Care Council
 Revised Assurance Process
 Quality Strategy Aligned to Cost
Improvement & Integrated
Business Plans
 Quality Impact
Assessments
DCHS Way










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Quality Dashboard
CQC Compliance
National Reports & Data e.g. QRP
Key Performance Indicators &
Performance Monitoring
Framework
Safety Express/Safety
Thermometer
Patient Reported Measures
Staff Reported Measures
Safety & Quality Board Visits
Early Warning Indicators
DCHS Way
6.5
The DCHS Quality Governance Framework
6.5.1 Quality Service Information
Reports to the Trust Board and associated governance structures (such as the
Quality Services Committee) have been revised, updated and improved through a
process of confirm and challenge by Board members. Our Quality Dashboard
reporting provides information which is timely and as up to date as possible. The
reports provide information in relation to performance against national and local
indicators, and encapsulate quantitative as well as qualitative information. During
2013/14 these reports have been developed further to increase the number of
metrics and include quality priorities, such as performance across services in relation
to the safety thermometer and patient experience. We continue to seek to influence
The National Quality Dashboard to increase the focus on community services. This
will ultimately provide an opportunity for benchmarking on a national basis and
against comparative organisations. Benchmarking data has been used to compare
the Safety Thermometer outcomes and we continue to explore opportunities to
benchmark quality measures and outcomes with other aspiring community
foundation trusts and providers of community services.
6.5.2 Identification of Risks to Quality and the identification of Quality Service
Key Performance Indicators (KPIs)
A Board Assurance Framework (BAF) is in place and is reviewed at Board and
subcommittee level. This, in combination with enhanced reporting to the Board, is
utilised to identify the key risks to the delivery of quality services.
Underpinning this is a number of systems and processes which enable the
identification of risk at individual, service, divisional, and corporate level. This
includes our Risk Management Strategy, utilisation of our ‘Top X’ risk process, the
review and interpretation of quality data at service, divisional and corporate level.
This includes the Trust Board, Quality Services Committee and subcommittees and
divisional governance structures. Our Quality Impact Assessment processes and
equality and diversity impact assessments are used alongside our IBP and service
efficiency programmes to ensure that any impact upon quality, equality and diversity
are monitored and that the Board is able to keep quality at the centre of everything
we do.
6.6
Quality Improvement
Our priories for Quality Improvement and the associated key performance indicators
(KPIs) are identified and reviewed each year. They are developed utilising our
knowledge about risk and then refined and prioritised with our staff and public
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(including our Governors and Foundation Trust members). Delivery against the KPIs
is the responsibility of everyone within the organisation. Our Board is accountable for
ensuring their delivery.
The quality priorities for 2014/15 continue to be focused on:



Keeping patients safe
Getting the basics right
Putting the patient at the centre of everything we do
These priorities reflect the values of the Trust which are embedded within the DCHS
Way as enshrined principles that will continue in future years.
Our focus upon quality improvement is to ensure that we make the delivery of our
services safer, effective, patient centred, timely, efficient and equitable35. These
dimensions of quality can be explained as follows.
Safe: reducing and preventing avoidable harm to patients whilst in our care.
Effective: providing services based upon clinical evidence and which produce a clear
benefit.
Person – Centred: Providing care that is responsive to individual patient needs and
where they and their cares are involved in planning and delivery of care.
Timely – reducing unnecessary waits or delays in treatment and care, especially
where this may be harmful.
Efficient – enabling our staff to work efficiently, in a well organised and competent
manner, with a more productive and empowering leadership at a local level.
Equitable – providing care that does not vary in quality dependent upon where
someone lives and how someone can access a service, who they are or what their
ethnicity, gender, status, or ability is
6.6.1 The Monitoring of Quality Improvement
Our quality performance dashboard, external and internal assurance systems (as
identified within the Board Assurance Framework and Quality Improvement and
Assurance Framework), enable us to focus upon performance and outcomes.
Quality Improvement and Assurance Framework
35
The Dimensions of Quality. Quality Improvement made simple. The Health Improvement
Foundation. www.health.org.uk
Page | 120
Our performance data is utilised from service delivery to the Board in order to support
the identification of risks to the delivery of quality services and identify areas for
improvement. The combination of a focus upon strategy, capabilities and culture,
processes and structure and measurement of performance data, provide a
framework for continuous quality improvement and assurance. We will also continue
to publish our Annual Quality Account, as required of all healthcare providers, (plus
subject them to external audit). This enables us to share with our public how we
delivered our services, what was achieved in terms of quality performance and
outcomes for patients and areas where we still have room for improvement. We are
also able to define the priority areas and commitments towards improving quality in
the year ahead.
Our service strategy over the next five years (as described within the DCHS
Integrated Business Plan) takes us upon an ambitious journey which features
significant change within our services. With this in mind it will be vital that our quality
governance systems continue to be reviewed and updated on a regular basis to
ensure that they are fit for purpose and we are able to be assured that the quality of
our services continues to improve and deliver the quality of care our patients
deserve.
6.6.2 Turning Strategy into Action
To support the delivery of high quality care and continuous service improvement with
measurement of outcomes we have:


Developed and implemented our Quality Strategy.
Developed our clinical strategy
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








6.7
Developed and implemented our Patient Engagement and Experience
Strategy.
Developed and implemented a quality improvement and assurance framework
Developed and tested Rapid Response Warning System
Developed and implemented our Quality Impact Assessment tool which is
incorporated and inherent within our Programme Management Office
Approach (PMO) to service planning and change.
Developed and implemented our Equality, Inclusion and Human Rights
Strategy. Embedded Equality Impact Assessments as a policy and service
improvement tool.
Reviewed and strengthened our quality governance processes – for example
the role and function of the Quality Services Committee and reporting
subcommittees. This also incorporates self-assessment against key
performance indicators and levels of assurance provided to the Board.
Embedded our Board Assurance Framework – which is aligned to
organisational risk, our governance processes and the assurance provided in
maintaining compliance against quality standards and requirements
Assessed ourselves as an organisation against the Monitor requirements for
all Foundation Trusts in relation to Quality (Quality Governance Assurance
Framework). We continue to progress this and improve our performance and
our evidence of assurance against this
Produced a Quality Account for the fourth year running. This year the process
has been assured by external audit (360 Assurance).
Quality Goals and Outcomes of Success
As we develop and embed our work in relation to patient safety, clinical effectiveness
and the patient experience, we will focus our clinical quality priorities in relation to the
quality priories already identified i.e.



Keeping patients safe
Getting the basics right
Putting the patient at the centre of everything we do
Our focus upon keeping patients safe is encompassed and measured as defined
within the Safety Express programme of safe care.
This is a reduction in pressure ulcers, falls, urinary tract infections (associated with
urinary catheters) and Venous Thromboembolism (VTE).
The use of Safety Express (which is the programme of safe care) and the Safety
Thermometer (which is the measurement tool) has been extended across our
inpatient and community teams. It also forms part of our essential training
programme for all staff’. In addition we will be enhancing our patient safety ambition
by focusing on reducing serious medicines prescribing and administration errors.
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‘Getting the basics right’ and ‘placing our patients at the centre of everything we do’
is being measured within our clinical audit programme, quality audits and patient
experience reporting. This includes the Family and Friends Test (the net promoter
score) which is being measured within a broad range of our service areas, with the
aim to extend the system as part of patient experience surveys across the trust.
Within this process we are asking patients if they would recommend our services to
family or friends and place a score against key areas of care delivery. This in turn
enables us to identify areas for improvement and measure on-going improvement.
We will also continue to focus upon the assurance the public, our commissioners and
our regulators require in relation to our services (both in terms of quality compliance
and the delivery of our service contracts). For example this includes safeguarding our
patients and public (meeting statutory and multiagency safeguarding requirements
and obligations under the Mental Health Act and mental Capacity Act) encompassing
children and vulnerable adults within a ‘think family approach’, maintaining
continuous improvement in infection prevention and control, meeting single sex
accommodation requirements, providing assurance in relation to the quality of care
when patients die in our care (SHMI) and maintaining a high reporting /low harm
approach in relation to incidents (including a focus upon the prevention of ‘Never
Events’) and the delivery of CQUINs (commissioning for quality improvements).
Key points of this section:





We have defined our approach to quality and this is related to The DCHS
Way
We are committed to continuous quality improvement
We are focusing upon measurement and outcomes of improvement
We have defined our priorities for quality improvement
We have strengthened our approach to quality improvement and
assurance
Page | 123
7
Financial Plans
Purpose of this section:
7.1

Review the historical performance of DCHS.

Outline the current performance of DCHS.

Detail the financial plans for DCHS over the next five years.
Introduction
In April 2011, Derbyshire Community Health Services NHS Trust was established
following the formal separation from Derbyshire County PCT. Since April 2009, the
Trust had been operating as an autonomous provider organisation within the PCT but
operating very much as an independent business unit, managing its own income &
expenditure and cash position. The preparatory work that was undertaken in the two
years prior to establishment as an NHS Trust, stood the new organisation in good
stead to meet the challenges as a standalone entity.
The Trust is now in its third year of operation and has already demonstrated a good
track record in the delivery of its financial targets. The Trust received unqualified
audit opinions with regards to the statutory accounts for 2011/12, 2012/13 and
2013/14.
During 2012/13, the Trust went through the final stage of the Monitor assessment
process to become authorised as an NHS Foundation Trust. Although, ultimately the
application was deferred, it was recognised that the Trust was financially viable and
that the financial plans submitted were robust.
As the Trust prepares to re-engage with the Monitor process the learning that has
been achieved as part of this process needs to be applied to the plans going forward.
In particular, the review of the Trust’s working capital projections highlighted a
number of areas where the Trust needed to improve its processes to ensure that
cash is maximised. This is of even more relevance now due to the new rating system,
Continuity of Service (COS) rating, which Monitor has recently introduced.
This refresh of the Trust’s Long Term Financial Model (LTFM) details the Trust’s
plans over the next 5 financial years extending out to 2019/20
The key financial objective over the life of the Integrated Business Plan is to support
the delivery of the service strategies within a sustainable financial plan. The Trust
does not underestimate the financial challenges it will face in the current and future
economic environment. However, the good financial management of the past, and
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the development of financial systems and processes going forward will place the
Trust in a strong position to thrive in the future.
This section provides an overview of the financial plans, and summary financial
tables. The detailed finances are included within the Long Term Financial Model
(LTFM). The section is based upon version 4 of the updated LTFM completed June
2014.
7.2
Historical Financial Performance
7.2.1 Financial Overview
Although the Trust was not established until 1 April 2011, it has operated as
financially separate within Derbyshire County Primary Care Trust since 1 April 2009
until the establishment date of 1st April 2011.
7.2.1.1 Statutory Financial Duties
The Trust has historically delivered all of its financial targets and met its statutory
duties. The table below provides a summary of financial performance against key
indicators. (Please note that in 2010-11, the Trust was still part of Derbyshire County
PCT).
Statutory Duties
Breakeven duty
Remain with Capital Resource Limit
Capital Absorption rate @ 3.5%
Remain within EFL
Actual
2010/11
Actual
2011/12
Actual
2012/13
Actual
2013/14
Y
Y
Y
N/A
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
The External Financing Limit (EFL) is a target set for NHS Trusts and sets a limit on
the amount of external finance that an NHS Trust may access in one year. As an
Autonomous Provider Organisation in 2010-11, this target was not applicable. The
2011-12 target was negative EFL of £1.23m. The Trust undershot this target by
£9.3m. NHS Trusts are permitted to undershoot. The Trust deliberately undershot
this target to allow it to maximise its cash balance as at 31st March 2012. In 2012-13,
the target was a net cash in-flow of £1.028m. The Trust undershot this target by
£1.8m. In 2013/14, the Trust undershoot the target by £0.799m.
7.2.1.2 Continuity of Service Rating (COS)
Monitor has recently introduced a new risk assessment framework. As part of this the
old Financial Risk rating methodology has been replaced with a Continuity of Service
(COS) rating.
Page | 125
The principle behind the new rating is to assess any organisation’s ability to continue
as a going concern and therefore its on-going ability to provide essential NHS
services. The new framework became operational from 1st October 2013.
This financial viability is assessed by the use of only two metrics both given equal
weighting.
Liquidity – This measures an organisations ability to meet its normal day to day
outgoings and is measured as the number of days operating expenditure that can be
met from current cash or cash equivalent forms. It is important to note that under the
COS rating, the working capital facility is specifically excluded but the threshold
levels have been adjusted accordingly.
Capital Servicing Capacity – This metric assess an organisations ability to service
its debt repayments from its income generation activities.
Given the debt structure of the Trust, the only annual debt repayment that is currently
factored into the plans for DCHS is the Public Dividend Capital repayment which is
set at 3.5% of net relevant assets. Clearly for Trust’s with more significant levels of
debt e.g. PFI schemes, this metric has the potential to reduce their overall rating
when compared to the old FRR methodology.
The table below shows what the Trust’s historic performance would have been if the
COS rating system had been in place. It is important to note this against the context
of the Trust’s history and that it didn’t achieve independent Trust status until 1 st April
2011 and until that point was still subject to the rules governing PCT’s cash balances.
This is reflected in the performance against the liquidity metric.
In addition, it is difficult to assess performance against the debt financing metric as
the only factor that contributes to this is the standard public dividend capital payment.
The Trust has not yet been required to make this payment due to the delay in the
transfer of the non-current assets. This metric only becomes relevant from 2014/15
onwards.
Continuity of Service Rating ( COS)
Metric
Liquidity - 50%
Debt Financing - 50%
2010-11
-4.8
N/A
3
4
2011-12
-1.8
N/A
3
4
2012-13
3.6
N/A
4
4
2013-14
8.5
N/A
4
4
Weighted Average
3.00
3.00
4.00
4.00
Overall COS
4.00
4.00
4.00
4.00
The table below shows the Trust’s historic performance against the previous
Financial Risk Rating (FRR) framework. This demonstrates that the Trust has
delivered an improving performance year on year. Due to the delay in the transfer of
Page | 126
non-current assets and the subsequent impact on the EBITDA margin, the overall
FRR has been restricted to a 3 in the first three years. In 2013/14, the hosting of
Leicester Elective Services dilutes margins and therefore the FRR remains at a 3.
Historic Financial Risk Ratings
Metric
EBITDA margin
4.75%
EBITDA, % achieved 100.00%
ROA
4.67%
I&E surplus margin
0.64%
Liquid ratio
22.8
2010-11
2
5
3
2
3
2011-12
1.36%
100.00%
49.60%
0.80%
29.0
2
5
5
2
4
2012-13
2.10%
123.30%
57.10%
1.50%
26.7
2013-14
4.00%
104.60%
6.30%
1.60%
32.9
3
5
5
4
4
2
5
5
3
4
Weighted Average
3.00
3.50
3.00
3.60
Overall FRR
3.00
3.00
3.00
3.00
7.2.2 Historic Income and Expenditure Position
The actual financial results of the last three years are disclosed in the table below
and demonstrate that the organisation has achieved a breakeven position and
growing surplus in each year.
Historic Income and Expenditure
Actual
2010-11
£m
Actual
2011-12
£m
Actual
2012-13
£m
Actual
2013-14
£m
Clinical Income
Other Income
142.6
22.6
168
16.1
172.1
16.2
171.3
11.2
Total Turnover
165.2
184.1
188.3
182.5
-150.1
-181.7
-184.4
-175.4
EBITDA
15.1
2.4
3.9
7.1
Depreciation
Impairments
Interest income
PDC Dividend Payable
-3.6
-7.3
0.0
-3.1
-1.1
-0.1
0.1
0.0
-1.2
0.0
0.1
0.0
-4.4
0.0
0.1
0.0
1.1
1.3
2.8
2.8
Operating Expenses
Surplus / ( Deficit) In Year
In 2010-11, the Trust was still part of Derbyshire County PCT and as such was still
subject to the financing arrangements of a commissioning organisation. The EBITDA
of £15.1m or 9.1% was artificially inflated due to the receipt of additional income
Page | 127
through the contract of £7.8m to support a fixed asset impairment. At this point, the
Trust still accounted for all of the relevant non-current asset portfolio within its books.
From 1st April 2011, the Trust became established as its own statutory organisation,
but at this point the non-current assets remained with the PCT. This had the impact
of moving a significant element of the Trust ‘s cost base from depreciation and PDC
costs to operating lease costs. This in return reduced the level of EBITDA margin
achieved in both 2011-12 and 2012-13.
The Trust’s clinical income grew by £26m in 2011-12, excluding impairment funding.
The main reason for this significant increase was due to the temporary hosting of
Leicester Elective Services with an annual contract value of approximately £21.5m.
The hosting arrangement ended on 31st March 2014. This service is now provided by
and Alliance of University Hospitals of Leicester, Leicestershire Partnership NHS
Trust and GP providers. The Trust did not tender for the service on the basis that
commissioners wanted a local solution to support their strategy for dealing with the
health economy’s financial sustainability.
7.2.3 Historic Normalised Position
In order to gain a greater understanding of the underlying financial position of the
organisation, adjustments have been made to exclude any one-off or non-recurrent
income and expenditure which are deemed not to be part of normal trading
expenses.
The material one off transactions were:



Impairment income and expenditure
Non recurrent re-provision of previous year’s surplus – due to the Trust being
an APO in 2010-11, the PCT agreed to repay the revenue surplus delivered by
DCHS in any one year. This was re-provided in the following year. 2011-12
was the last year that DCHS received this non recurrent funding.
Service reconfiguration costs
This results in a normalised position for each of the years in question as disclosed in
the table below.
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Normalised
Turnover - Contract Income
Turnover - Other Income
Total Turnover
Normalised
Normalised
Normalised
Out-Turn
Out-Turn
Out-Turn
Out-Turn
Out-Turn
Out-Turn
Out-Turn
Out-Turn
2010-11
2010-11
2011-12
2011-12
2012-13
2012-13
2013-14
2013-14
£m's
£m's
£m's
£m's
£m's
£m's
£m's
£m's
142.6
22.6
165.2
133.4
22.6
156.0
168.0
16.1
184.1
167.0
16.1
183.1
172.1
16.2
188.3
170.7
16.2
186.9
171.3
11.7
183.0
171.3
11.2
182.5
-150.1
148.8
181.7
181.7
184.4
182.4
-174.9
-175.5
EBITDA
15.1
7.2
2.4
1.4
3.9
4.5
8.1
7.0
Depreciation & Amortisation
PDC Dividend
Impairments
Surplus
-3.6
-3.1
-7.3
1.1
-3.6
-3.1
0.0
0.5
-1.0
0.0
-0.1
1.3
-1.0
0.0
0.0
0.4
-1.1
0.0
0.0
2.8
-1.1
0.0
0.0
3.4
-4.4
0.0
-0.9
2.8
-4.4
0.0
0.0
2.6
9.14%
4.62%
1.30%
0.76%
2.07%
2.41%
4.43%
3.84%
Total Operating Costs
EBITDA Margin %
The EBITDA margin in both 2011-12 and 2012-13 falls due to the issue of the noncurrent asset transfer as referred to earlier. This recovers again in 2013/14 when the
assets transfer to the Trust and this is reflected in higher levels of depreciation costs
being incurred from this point onwards.
The Trust has not required any financial support since becoming established as an
APO in April 2009.
7.2.4 Historic Cost Improvement Performance
The Trust has consistently delivered its cost improvement targets as demonstrated
below.
In 2010-11, the Trust identified 100% of the required savings on a recurrent basis
and delivered a non-recurrent over-achievement of just over £200k.
In 2011-12, the recurrent shortfall of £700k was factored into the planning
assumptions for the following year and in 2012-13, the full requirement was delivered
on a recurrent basis.
This track record of successful delivery of its cost improvement programme will put
the organisation in a strong position to meet the financial challenges ahead.
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Historic Cost Improvements
Actual
2010/11
£m
Actual
2011/12
£m
Actual
2012/13
£m
Actual
2013/14
£m
Recurrent requirement
5.3
6.9
9.2
8.1
Recurrent savings
Non Recurrent savings
5.3
0.2
6.2
0.0
9.2
0.9
8.4
0.0
Recurrent Shortfall
0.0
0.7
0.0
0.0
Previous cost improvement schemes have included the following:






Significant reductions in length of stay, reducing the demand for inpatient
beds, through the JONAH project
Using the Improving Leadership Programme to identify opportunities to drive
out waste, waiting and duplication
Introduction of mobile working and increasing the use of “hot desk” facilities to
improve productivity of staff
Improved sickness and absence management reducing the need to backfill
staff through bank and agency
Skill mix reviews across all services to align staffing skills to patient need
Procurement efficiencies including product standardisation and maximising
opportunities under collaborative purchasing arrangements
Energy efficiency programmes that released cost savings as well as
supporting the Trust’s carbon reduction plan
7.2.5 Historic Balance Sheet
The table below shows the Trust’s historic balance sheet position.
During 2010-11, as the Trust was still part of the PCT, all the relevant non-current
assets were recorded on the Trust’s Balance sheet. However, upon establishment as
an independent NHS Trust on 1st April 2011, the non-current assets, with the
exception of equipment assets, remained with the PCT until the abolition of the PCT
at the end of 2012-13.
This is the reason why the total non-current assets fall from £69m at the end of 201011 to just £4.4m at the end of the following year.
Page | 130
Historic Balance Sheet
2010-11
£m
2011-12
£m
2012-13
£m
2013-14
£m
Non Current Assets
69.0
4.4
4.4
81.0
Current Assets
12.6
21.8
17.2
21.3
-14.4
-22.4
-15.5
-17.2
-1.8
-0.7
1.7
4.1
Provisions - Non Current
0.0
-0.1
0.0
0.0
Deferred Income - Non Current
0.0
0.0
0.0
0.0
67.2
3.6
6.1
85.1
Public Divided Capital
Retained Earnings
Revaluation Reserve
51.9
0.0
15.3
0.0
3.5
0.1
-0.4
6.4
0.1
-0.2
67.3
18.0
Total Assets Employed
67.2
3.6
6.1
85.1
Current Liabilities
Net Current Assets / Liabilities
Total Assets Employed
Represented By:-
For two years, the assets were leased back to the Trust via an operating lease
arrangement. Following the abolition of the PCT, the relevant non-current assets
transferred to the Trust via a Transfer order. The value of the transfer is
approximately £76m. This is reflected in the balance sheet position for 2013-14
detailed later in this section.
As at 1st April 2011, the Trust successfully negotiated an opening cash balance of
£8.4 million to be included within the opening balance sheet as a debtor. This debtor
was calculated based upon the accumulated cash surpluses generated as an
Autonomous Provider Organisation and the cash to back the working balances that
the NHS Trust was taking on.
Over the past couple of years, the Trust has undertaken some proactive work to
understand and to influence it’s working capital balances and therefore maximise its
cash position. This work is ongoing in readiness for re-engagement with the Monitor
assessment process. However, it is important to note that in July 2013, the Trust
received a clean working capital opinion from the Price WaterHouse Cooper and was
successful in securing a working capital facility from a commercial bank.
The Trust does not hold any Private Finance Initiative (PFI) assets. The Trust does
lease some space in a number of LIFT properties in the south of the Derbyshire. The
head lease for these properties is held by Community Health Partnerships.
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7.2.6 Historic Cash-flow
The table below sets out how cash was generated and utilised over the last three
financial years.
2010/11
£000's
Cash Required
Investment in working capital
Capital investment
PDC repaid
Repayment of loan capital
Payment of dividends
Interest Payable
2011/12
£000's
2012/13
£000's
2013/14
£000's
-3,671
-5,927
0
0
-3,275
0
0
-1,477
0
0
0
0
-2,238
-1,244
-357
0
0
0
-2,574
-5,036
0
0
0
0
-12,873
-1,477
-3,839
-7,610
7,842
0
0
0
0
5,049
2,483
9,508
0
0
18
0
3,819
0
351
0
37
0
8,168
0
0
185
55
0
12,891
12,009
4,207
8,408
Opening Cash Position
15
33
10,565
10,933
Closing Cash Position
33
10,565
10,933
11,731
Funded by:
Operating Cash Flows
Investment in Working Capital
Asset disposals
PDC Funding
Interest received
PCT Capital ( 2010/11 only)
The cash generated through the EBITDA surplus has principally been used to fund
capital investment and to manage fluctuations in working capital balances. It is
important to view the historic cash flow information in the context of an Autonomous
Provider Organisation operating within the PCT cash management regime.
The investment in working capital of £3.7m in 2010-11, relates to the in-year impact
of the cash funding agreed with Derbyshire County PCT to support the Trust’s
opening Balance Sheet position. The repayment of this is reflected in the positive
cash inflow from working capital in 2011-12.
The line “Adjustment re PCT Capital” reflects the fact that as an APO and part of a
PCT in 2010-11, the Trust received a Capital Resource Limit which was cash backed.
As a PCT, the cash saved from depreciation and capital charges / PDC dividend is
top-sliced centrally by the Department of Health and PCT received capital resource
and cash.
The historic and forecast outturn position against the Public Sector Payment Policy is
shown below:
Page | 132
Better Payment Practice Code
No
Non NHS invoices
NHS invoices
2010-11
Value
%
%
2011-12
No
Value
%
%
98.12% 91.09% 97.04%
94.72% 96.28% 98.99%
96.72%
97.13%
2012-13
No
Value
%
%
97.00% 97.00%
98.00% 100.00%
2013-14
No
Value
%
%
97.30%
98.30%
97.00%
97.60%
The Trust met 2 out of 4 of the targets in 2010/11, 4 out of 4 in 2011/12 ,2012/13 and
2013/14.
7.2.7 Historic Capital Investment and Disposals
Capital investment plans over the past three years are shown in the table below.
Capital Investments
Actual
Actual
Actual
Actual
2010/11
2011/12
2012/13
2013/14
£000s
£000s
£000s
£000s
IBP Delivery / Other
2,997
109
338
1,605
0
801
683
0
0
1,111
320
0
2,997
1,267
318
0
Total
5,049
1,484
1,431
4,582
Statutory/ Backlog Maintenance
IM&T Strategy
Equipment
The capital investment of £5m in 2010/11 reflects that fact that the Trust accounted
for the non-current assets in that year.
In the following two financial years, there was a reduced level of capital investment
reflecting the fact that the assets were retained by Derbyshire County PCT. In those
years the most significant investment was to support the rollout of the IM&T strategy
which in turned supported the clinical service strategy.
In 2013/14 the non-current assets transferred to the Trust and this is reflected in the
increased capital investment in that year.
7.3
Future Planning Assumptions
7.3.1 Introduction
The financial environment in which the Trust is operating continues to be challenging.
The Trust will also need to be mindful of the financial position of local clinical
commissioning groups, and the challenges they face in delivering their financial
targets.
Page | 133
The Trust is operating in an increasingly competitive environment. A number of
service lines have already been market tested and the Trust has a good track record
of successfully retaining business. We have won the last 5 tenders submitted. Over
the planning period, there are a significant number of other services that are to be put
out to tender and the organisation is well placed to respond to the challenge.
As well as retaining existing contracts, the Trust also sees the more competitive
environment as an opportunity to expand its services and to compete for additional
contracts. The Trust has developed its commercial capability to enable it to respond
positively to these risks and opportunities.
In preparing the financial plans for the future the Trust has constructed a base case
which is driven by a set of realistic assumptions.
As an aspirant Community Foundation Trust, it is critical that the organisation
demonstrates sound financial planning and demonstrates financial viability. Detailed
financial modelling has been carried out to support the development of the Integrated
Business Plan. The Long Term Financial Model (LTFM) shows the commitment to
deliver a continuity of service rating of a 4, the maximum that can be achieved,
throughout the life of the model.
The plan is predicated on the successful achievement of cost improvements of circa
£40.0m over the 6 year period including the current year and equates to an average
of 4. 38% of the forecast cost base per annum.
The key assumptions on which the Long Term Financial Model (LTFM) is based
revolve around:






Activity
Income
Expenditure
Cost Improvement Plans
Capital Expenditure
Balance Sheet
These assumptions have been benchmarked against guidance in the Operating
Framework 2014/15, Monitor planning guidance, Trust Development Agency and HM
Treasury guidance, and discussions with other NHS organisations.
7.3.2 Activity Assumptions
7.3.2.1 Health Economy Assumptions
The Derbyshire health and social care economy have engaged Finnamore to
undertake some planning work to support the submission of 5 year plans in June
2014. There are two pieces of work being undertaken.
Page | 134
The first is countywide, which brings together the activity and financial planning
assumptions across commissioner and providers to support the triangulation of these
plans.
The second piece of work is in the North Derbyshire Unit of Planning, which covers
North Derbyshire CCG and Hardwick CCG. This work aims to bring together a
system wide service plan which will be used as the basis for a public consultation on
the future of health services in the area. This work will also include the modelling of
future activity assumptions.
The activity assumptions used by the Trust has been informed by this work to ensure
that there is system alignment around planning assumptions going forward.
The outputs are reflected in this version of the model.
7.3.2.2 Cost and Volume Activity
The Trust has worked with the divisions to develop a set of realistic assumptions
around activity changes over the five years of the LTFM. The starting point has been
to review the outturn position by service line for 2013/14, and then model the
following changes:




Impact of service model changes
Impact of demographic growth
Impact of planned efficiencies / investments (where known)
Impact of CCG service plans (where known)
The majority of C&V activity increases are in line with estimated population growth
across Derbyshire.
The main exception is Community Podiatry activity which is planned to increase by
30% over the life of the model. This is in line with historical levels of activity growth
and is anticipated to continue increasing due to the anticipated increase in diabetes
diagnosis, increasing elderly population and through targeted marketing by the
service. Some specialities in Planned Care, Ophthalmology and Trauma and
Orthopaedics , are also anticipated to increase slightly greater than demographic
growth.
The table below details the current activity assumptions that underpin the clinical
income values modelled in this latest version of the plan.
Page | 135
Summary of Cost and Volume Activity Assumption
Service
Accident & Emergency
Planned Care Out Patients
Diagnostic Imaging
Community Podiatry
Physiotherapy
Speech & Language Therapy
Podiatric Surgery
Vasectomy
14/15
15/16
16/17
17/18
18/19
19/20
55,403
42,230
2,261
149,287
115,862
15,825
14,646
449
55,747
43,342
2,276
157,299
116,649
15,950
14,746
452
56,087
44,732
2,292
165,791
117,443
16,078
14,846
455
56,429
45,277
2,308
174,791
118,241
16,203
14,947
457
56,818
45,872
2,325
184,330
119,057
16,337
15,050
460
57,159
46,467
2,341
194,441
119,867
16,466
15,153
463
Cumulative activity
change 14/15 to 19/20
1,756
4,237
80
45,154
4,005
641
506
14
3.2%
10.0%
3.6%
30.2%
3.5%
4.0%
3.5%
3.0%
7.3.2.3 Block Contract Activity
Service Line Summary
Community
Community
Community
Community
Inpatient
Inpatient
Inpatient
Outpatient
Outpatient
Outpatient
Summary of Block Activity Assumption
14/15
15/16
16/17
Learning Disability
Scheduled Adult Services
Scheduled Childrens Services - School Nursing
Scheduled Childrens Services - Health Visiting
Learning Disability
Older Peoples Mental Health (Spells)
Rehabilitation and Continuing Care (Spells)
Dental
Disability Equipment
Learning Disability
9,702
517,092
20,409
104,431
1,036
361
3,348
50,783
30,119
3,043
9,765
562,148
20,409
105,602
1,043
361
3,140
51,128
30,721
3,060
9,816
608,441
20,409
106,307
1,048
361
3,002
51,476
31,336
3,077
17/18
18/19
19/20
Cumulative
9,879
634,698
20,409
106,544
1,054
361
3,002
51,831
31,962
3,094
9,942
662,385
20,409
106,544
1,061
361
3,002
52,184
32,602
3,112
10,006
691,583
20,409
106,544
1,068
361
3,002
52,549
33,254
3,129
304
174,491
0
2,113
32
0
-346
1,766
3,135
86
3.1%
33.7%
0.0%
2.0%
3.1%
0.0%
-10.3%
3.5%
10.4%
2.8%
The Trust’s strategic plans to move more activity from an inpatient setting to the
community is reflected in the activity plans detailed above with a steady reduction in
planned inpatient spells and a corresponding increase in community contacts as the
service model changes are fully implemented. In addition investment of £2.2m has
been assumed from CCG’s from the Better Care Fund which is assumed will be
invested into the community in 15/16 and 16/17, the anticipated increase that this will
have on Community Adult Services has therefore also been included above.
Growth in line with local population growth has generally been assumed across other
services except in the following cases.
Wheelchairs activity is assumed to increase 2% year on year in-line with historical
activity.
Older Peoples Mental Health activity is expected to stay static overall with increases
in demographic growth being off-set by no longer admitting Functional patients who
should not be seen in DCHS beds, therefore no increase in activity or income has
been assumed
7.3.3 Income Assumptions
The clinical income assumptions have been updated to reflect the current projections
regarding income levels over the medium term. In particular, there are a number of
service lines within the Health, WellBeing and Inclusion division that will be market
tested over the next two years. The most significant impact of this will be in 2015/16.
If the Trust is successful in retaining this business it is likely that the contractual
Page | 136
envelope will be up to 15% less than currently received. The financial plans as
presented here therefore assume that an additional CIP is achieved to maintain the
overall service costs within the reduced financial value. In reality, it is likely that each
service will attract a differing level of investment from commissioners, but as yet this
has not been clarified
Detailed work has now been undertaken to assess the likely impact of demographic
growth over the planning period on the Trust’s income and activity levels. In addition,
the Trust has now modelled additional investment from the Better Care Fund. This
has been informed by the work that Finnamore have been commissioned to
undertake on behalf of the local CCGs. The Trust has taken a prudent approach
regarding the level of margin that will be attached to this income going forward, as
margins are expected to be squeezed on new business, and has modelled a 12%
margin from 2015/16 reducing to 9% by 2018/19. The current margin used is 15%.
The only exception to this is in respect of planned care activity where the margins
historically have been higher, and payment is based upon tariff.
For planning purposes, for the Health Visiting contract only from 2015/16 onwards it
is assumed that a % uplift in line with the national pay award will be received. The
Health Visitor contract requires the Trust to have a certain number of posts, and
therefore it is not possible to deliver efficiencies if post numbers are fixed. This has
been agreed with commissioners who have this arrangement with other providers.
In addition, for those service lines which are now commissioned by local authority
partners, the Trust has assumed that following the tender process and the significant
reduction to the contractual envelope, that an annual uplift again equivalent to the
NHS pay award will be received.
For all other service lines, the table below details the current assumptions within the
LTFM regarding tariff deflation for the next five years.
The 2014/15 and 2015/16 agenda for change inflationary uplifts apply only to those
staff who will not be eligible to receive an incremental point increase in that year. In
addition this award is non-consolidating. For planning purposes, the Trust has
removed the recurrent impact of this in 2016/17 by increasing the level of tariff
deflator forecast for that year which will in effect remove the cumulative impact of this
2 year award from the Trust’ cost base.
Page | 137
Base Case Assumptions
2014/15
%
2015/16
%
2016/17
%
2017/18
%
2018/19
%
-1.80%
-1.80%
-1.80%
-1.80%
-1.80%
-1.80%
-1.80%
-1.60%
-1.60%
-1.60%
-1.60%
-1.60%
-1.60%
-1.60%
-0.70%
-0.70%
-0.70%
-0.70%
-0.70%
-0.70%
-0.70%
-0.60%
-0.60%
-0.60%
-0.60%
-0.60%
-0.60%
-0.60%
-0.70%
-0.70%
-0.70%
-0.70%
-0.70%
-0.70%
-0.70%
2019/20
%
LTFM Heading :Cost & Volume - Inpatients
Cost & Volume - Outpatients
Cost & Volume - Community Services
Block - Inpatients
Block - Outpatients
Block - Community Services
Other Operating Revenue
-0.70%
-0.70%
-0.70%
-0.70%
-0.70%
-0.70%
-0.70%
The portfolio changes that have been modelled in the base case are as follows:
Leicester Elective Services – The Trust is no longer commissioned to provide
this service with effect from 1st April 2014
Historically levels of private patient income generated within the Trust have been
minimal and the base case assumes no significant change.
The Trust’s main areas of non-clinical income are service level agreements with other
NHS providers , training and education funding and income generated from the
catering and estate departments. For a number of these income streams the Trust
has taken the view that it is not realistic to apply a deflationary factor as in reality
these specific income streams will at worst remain static but in some cases the levels
recovered will increase year on year.
7.3.4 Expenditure Assumptions
The inflation assumptions within the base case are as set out in the table below.
Base Case Assumptions
2014/15
%
2015/16
%
2016/17
%
2017/18
%
2018/19
%
1.00%
1.00%
4.00%
2.10%
2.10%
3.80%
1.00%
1.00%
4.00%
2.50%
2.50%
3.80%
0.40%
1.00%
4.00%
3.00%
3.00%
3.80%
1.70%
1.00%
4.00%
3.20%
3.20%
3.80%
1.70%
1.00%
4.00%
3.00%
3.00%
3.80%
2019/20
%
LTFM Heading :Employee Benefit Expenses Inflation
Employee Benefit Expenses Pay Drift
Drugs
Clinical Supplies & Services
Other Non Pay
Capital Charges
Page | 138
1.70%
1.00%
4.00%
3.00%
3.00%
3.80%
The assumptions have been benchmarked against the latest Monitor expectations
around implied efficiency requirements for NHS organisations and with other local
providers.
The key material cost pressures included within the model are set out below:








Continued provision of a recurrent general risk mitigation reserve in 2014/15 to
the value of £1.5m increasing to £2.0m from 2017/18
1.0% recurrent increase in employee benefit costs each year for incremental
drift
Provision for increased employer on-costs in respect of pension contributions
from 2015/16 and national insurance contributions from 2016/17.
Creation of an additional inflation and cost pressures contingency reserve
Continued provision of a recurrent reserve to fund costs of implementing
CQUIN schemes
IM&T strategy revenue costs
IM&T strategy capital charge costs
Costs of the working capital facility – as agreed with the Trust’s preferred
provider.
A summary of the cost of these pressures is included within the table below:
Cost Pressures
Included in
Forecast
Forecast
Forecast
Implied Efficiency?
2014/15
2015/16
2017/18
Y/N
£000s
£000s
£000s
General Mitigation Reserve
N
Restructure Reserve
N
Staffing for Quality
N
CQUIN Reserve
N
Working Capital Facility
N
1,500
2,000
500
1,000
325
40
The table above details the reserves and contingencies that will be available in
2014/15. These reserves will be available to commit on a non-recurrent basis over
the life of the plan. However, if they are subsequently committed on a recurrent basis
they will not then be available in future years.
In 2015/16, an additional recurrent reserve is created to cover any non-recurrent
restructure costs that the Trust may incur as a result of the implementation of the
Integrated Business Plan.
The General Mitigation Reserve is uncommitted. This reserve will be used to mitigate
against any unforeseen downside pressures. The value of this reserve is planned to
increase to £2.0m from 2017/18.
The CQUIN reserve is in addition to funds already included within the recurrent
baseline. , The Trust has already invested £168,000 on a recurrent basis to support
Page | 139
the delivery of the annual CQUIN targets. Once the CQUIN schemes are signed off,
this reserve will be reviewed. This reserve will be committed on a non-recurrent basis
each year.
The table below details the incremental increases over the life of the plan for all other
reserves. These will be committed on a recurrent basis to fund pressures around
employee benefit expenses and unavoidable non pay rises and to support the
revenue consequences of the rollout of the Trust’s IM&T Strategy.
Cost Pressures
Forecast
Forecast
Forecast
Forecast
Forecast
Forecast
Implied Efficiency? 2014/15
Included in
2015/16
2016/17
2017/18
2018/19
2019/20
£000s
£000s
£000s
£000s
£000s
Y/N
Pay Award Reserve
Y
Incremental Drift
Y
Increased Pension Costs
Y
Increased NI Costs
Y
IM&T - New Investment in year
N
Cost Pressure Reserve
Y
£000s
1,058
1,173
0
0
240
850
1,091
1,094
328
0
240
951
483
1,080
0
1,134
240
1,121
1,856
1,090
0
0
240
1,187
1,844
1,076
0
0
240
1,052
1,822
1,063
0
0
240
1,084
7.3.5 Capital Investment Plans
A five year Capital Investment strategy has been developed with core themes of
IM&T infrastructure, maintenance of the rationalised estate, schemes to enable
implementation of the IBP, and routine rolling programmes of equipment
replacements. The base case assumes that this can be funded from internal cash
resources and that the Trust will not be required to secure loan financing.
It is not planned to secure any finance from the Private Finance Initiative.
Financial Plans – 4th Refresh 2014/15 to 2019/20
7.4
7.4.1 Introduction
This section provides a summary of the outputs from the Long Term Financial Model.
7.4.2 Continuity of Service (COS) Rating
The base case scenario demonstrates that over the life of the plan, a COS rating of a
4 is achieved in all years. This is the maximum rating that can be achieved under this
system and reflects the Trust’s relatively stronger position against this rating when
compared to the previous FRR methodology.
There are two factors contributing to this improvement:
Firstly the Trust has a strong liquidity position, The Trust’s audited Accounts
show that the Trust ended the financial year 2013/14 with a cash balance in
excess of £11.7m. Whilst this was slightly overstated due to working capital
variations, the underlying cash position remains healthy.
Page | 140

Secondly, the Trust has no debt financing and therefore the only debt
repayment that needs to be made on an annual basis is the standard PDC
dividend that all NHS organisations are required to make based on 3.5% on
average net relevant assets.
In a further change from the old FRR rating system, most working capital facilities are
excluded from the liquidity calculation.
The rationale for the exclusion of the majority of organisations’ working capital
facilities is that under a scenario where an organisation is in financial difficulty, the
default clauses contained within most of the agreements available on the market,
would render these facilities null and void and therefore it would not be appropriate to
include in the calculation of cash or cash equivalent resources available to the
organisation.
As the Trust prepares to engage again with Monitor assessment process,
consideration will need to be given as to whether a working capital facility is required
given the Trust’s underlying cash position and strong performance against the COS
rating. The level of cash headroom under the updated base case scenario is
discussed in more detail within the sensitivity section.
Clearly, protecting the Trust’s strong cash position will be vital to ensure that a sound
COS Rating is maintained in the future. This will allow the organisation to absorb a
short term fall in margins without a detrimental impact on its overall risk rating. This
places even greater emphasis on the delivery of the planned recurrent cost
improvement programme in future years as any material non achievement will erode
both margins and the current cash headroom available. Any significant erosion of this
position will have a detrimental impact on the assessment of the Trust as a viable
going concern.
The COS rating planned within the current base case scenario are detailed in the
table below.
Continuity of Service Rating ( COS)
Metric
Liquidity - 50%
Debt Financing - 50%
2014-15
10.0
3.4
4
4
2015-16
13.6
3.8
4
4
2016-17
28.1
4.2
4
4
2017-18
33.5
4.7
4
4
2018-19
48.3
5.3
4
4
2019-20
65.7
5.9
4
4
Weighted Average
4.00
4.00
4.00
4.00
4.00
4.00
Overall COS
4.00
4.00
4.00
4.00
4.00
4.00
In 2016/17, the liquidity metric improves from 13.6 days to 33.5 days, whilst the
forecast margins will generate a cash surplus, this will also be driven by the
Page | 141
proposed capital receipt from the sale of surplus land on the Walton site. This is
discussed in more detail in the section on “Capital Investment Plans”.
It is important to understand the sensitivity of the base and the level of headroom
available before a deterioration in the overall rating would occur. Based on the
current model, a reduction to EBITDA margin in 2014/15 of £4.6m would result in a
reduced score of the capital servicing metric and an overall drop to a rating of a 3. A
further reduction in margin of £1.5m would impact on both metrics sufficiently to
reduce the overall COS rating to a 2.
7.4.3 Financial Risk Ratings
Although Monitor has introduced a new governance framework and a new
methodology for assessing the financial viability of Foundation Trusts, it is good
practice for the Trust to continue to monitor itself against the previous Financial Risk
Rating (FRR) regime alongside the COS framework.
This is particularly useful when the Trust is assessing the current financial headroom
within the current base case model and in the context of the Trust’s relatively
stronger position against the COS system than under the previous regime.
The table below shows how the Trust’s updated LTFM projections would benchmark
against the FRR methodology.
Financial Risk Ratings
Metric
EBITDA margin
EBITDA, % achieved
ROA
I&E surplus margin
Liquid ratio
2014-15
5.40%
77.80%
2.30%
1.30%
38.1
3
3
4
3
4
2015-16
6.30%
77.80%
3.80%
2.20%
42.0
3
3
3
4
4
2016-17
6.90%
100.00%
4.60%
2.70%
56.1
3
5
5
4
4
2017-18
7.60%
100.00%
5.50%
3.40%
61.3
3
5
5
5
5
2018-19
8.50%
100.00%
6.70%
4.40%
76.0
3
5
5
5
5
2019-20
9.20%
100.00%
7.70%
5.30%
93.2
3
5
5
5
5
Weighted Average
3.45
3.45
4.05
4.50
4.50
4.50
Overall FRR
3.00
3.00
4.00
5.00
5.00
5.00
It is interesting to note that under the FRR system, the Trust would record a score of
a 3 in 2014/15. This compares to a COS score of a 4 in that year. This is due to the
FRR ratings having a stronger emphasis on in year income and expenditure
performance. The current LTFM plans for a surplus of only £2.0m or 1.3% of
turnover in 2014/15. This rises from 15/16 onwards and the FRR score recovers
accordingly.
In 2014/15 a reduction in margin achieved of £5m would result in the overall FRR
scoring a 2 due to the I&E margin dropping to a 1 thereby limiting the overall score to
a 2.
Page | 142
7.4.4 Forward Financial Risk Ratings
Monitor has identified a number of forward financial risk ratings which are used to
identify early warnings of potential financial problems at foundation Trusts.
The Trust planned performance against these indicators is shown below:
Indicator
Forecast
Forecast
Forecast
Forecast
Forecast
2014/15
2015/16
2016/17
2017/18
2018/19
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
Interim Fiannce Director in
place over more than one
quarter end
√
√
√
√
√
Quarter end cash balance <
10 days of operating
expenses or < £4 million
√
√
√
√
√
Capital expenditure < 75%
of plan for th year to date
√
√
√
√
√
Debtors > 90 days past due
date for 5% of total debtor
balances
Creditors > 90 days past
due account for > 5% of
total creditor balances
Two or more changes in
Finance Director in a 12
month period
7.4.5 Income and Expenditure
Under the Base Case, the Trust is forecasting the delivery of a surplus in excess of
1% of turnover in each year and an EBITDA margin of between 5.54% and 9.2%.
The summary I&E position is disclosed in the table below.
It is important to note the current planning assumptions upon which the plan as
presented here is based.

Employee Benefit Expenses –. The plan provides for forecast cost increases
over the planning period in respect of incremental drift, national pay award and
increases advised to employer pension and national insurance contributions.

A number of the Trust’s service lines within the Health Wellbeing and Inclusion
division will be market tested over the next couple of years. As part of this it is
possible that the financial envelope for this cohort of services could be up to
15% less than current levels. This l iteration of the plan has modelled this
decrease in clinical income offset with a corresponding CIP scheme to reduce
costs accordingly. In reality it is likely that there will be differential impacts at
individual service line. The Trust will review this with the services when better
information about commissioner intentions is received.
Page | 143

Public Dividend Capital – From 2014/15, the Trust will be liable to pay a 3.5%
charge on average net relevant assets. This charge was not payable in
2013/14. This has been factored into future years plans based on the current
Balance Sheet projections.
Income and Expenditure - Base Case
Forecast Forecast Forecast
2014-15 2015-16 2016-17
£m
£m
£m
Forecast
2017-18
£m
Forecast
2018-19
£m
Forecast
2019-20
£m
Clinical Income
Other Income
149.5
9.1
149.6
9.0
152.7
9.1
154.9
9.1
157.0
9.2
159.3
9.2
Total Turnover
158.6
158.6
161.8
164.0
166.2
168.5
-150.1
-148.6
-150.7
-151.6
-152.2
-152.9
8.5
10.0
11.1
12.4
14.0
15.6
Depreciation
Interest Income
-4.1
0.1
-4.1
0.1
-4.2
0.1
-4.3
0.1
-4.2
0.1
-4.1
0.1
PDC Dividend Payable
-2.5
-2.6
-2.6
-2.7
-2.6
-2.6
2.0
3.4
4.4
5.5
7.3
9.0
Operating Expenses
EBITDA
Surplus / ( Deficit) In Year
The current base case plans for an increasing EBITDA margin and net surplus from
2014/15 To 2019/20.
7.4.5.1 Employee Benefit Expenses
Staff costs equate to 68% of the Trust’s cost base. The workforce figures in the
finance section relate to funded established posts, which may be filled through
overtime or bank staff.
The workforce plans indicate a reduction in WTE numbers from 1st April 2014 over
the next three years of approximately 377 WTEs. This includes the WTE reduction to
the discontinuation of the hosting arrangement regarding Leicester Elective Services.
The 2013/14 average worked WTE out-turn is 3,414.83 compared to an opening
baseline position of 3,459.43 and represents a net increase of 44.6 WTEs. This will
include the impact of the significant investment that has been made by the local
CCGs as part of the Transformational programme. Most of the schemes only started
Page | 144
part way through 2013/14 and the increase will reflect the full year effect of the
increase to funded establishment levels on the yearly average.
The table below details the latest refresh of the future workforce reductions by staff
group and shows that the actual current WTE in March 2014 of 3,415 will fall to 3,091
by 31st March 2017.
Base Case Workforce Plans - ( Avg Worked WTEs)
Staff Group
Actual
Baseline
Planned
31/03/2014 2014/15 31/03/2015 31/03/2016 31/03/2017
WTEs
WTEs
WTEs
WTEs
WTEs
Consultant Costs
Dental
Junior Medical Costs
Nursing,
Scientific, therapeutic & technical
Other clinical staff costs - other
Non clinical staff costs
Leicester Elective Services
5.00
30.34
9.88
1,189.00
532.68
296.10
1,149.25
219.56
5.00
29.80
9.60
1,232.54
532.58
300.30
1,142.37
219.56
5.00
31.03
11.50
1,235.70
542.28
307.59
1,072.08
0.00
5.00
31.30
13.38
1,241.30
560.37
245.20
1,055.42
0.00
5.00
30.17
13.88
1,250.43
582.27
214.12
1,013.83
0.00
TOTAL
3,431.81
3,471.75
3,205.18
3,151.97
3,109.70
The figures in the above table relate to the planned year end WTEs.
The change in the workforce profile over the next two year period is explained
through the bridge analysis below.
Staff Group - WTES
( Worked WTEs)
01/04/2014
Baseline
Consultants
Junior Medical
Nursing
Dental
STT
Other Clinical
Non Clinical
5.00
9.60
1,232.54
29.80
532.58
300.30
1,142.37
Leicester Elective Services
Total WTEs
219.56
3,471.75
2014/15
CIP
Other
-17.84
-0.77
-1.30
-4.80
-48.29
1.90
21.00
2.00
11.00
12.09
-22.00
-73.00
-219.56
-193.57
Page | 145
2015/16
CIP
Other
2016/17
CIP
Other
-1.50
-20.98
0.00
-20.48
-1.40
0.00
-32.74
-46.45
5.00
0.50
13.88
29.61 1,250.43
0.27
30.17
21.90
582.27
1.66
214.12
4.86 1,013.83
-101.07
0.00
58.80 3,109.70
0.00
-62.39
-20.20
-105.07
3.38
26.58
0.27
18.09
3.54
51.86
2016/17
Forecast
The baseline position at 1st April 2014 is 3,471. By the end of the 20116-17, the Trust
plans to have reduced its workforce down to 3,110. This represents a reduction of
362. Of this 220 relates to Leicester Elective Services. The Trust’s current model
assumes that this hosting arrangement ceases on 31st March 2014. This leaves a net
reduction of 142WTEs which is achieved through the cost improvement plans net of
any necessary reinvestment to deliver the service model changes underpinning the
financial projections. The other column shows the forecast workforce changes
modelled during 2014/15 and includes the investment in qualified nursing staff to
support the Staffing for Quality initiative and the increase to the numbers of Health
Visitors employed by the Trust.
In the following two years apart from the changes planned as part of the Trust’s cost
improvement programme, investment is required in nursing and therapy staff to
deliver the anticipated activity growth due to population demographics as well as
strategic investment by commissioners as part of the Better Care Fund.
7.4.5.2 Other Operating Expenses
There is a significant reduction in other operating expenses in 2014/15. This is due
again to the Trust not providing Leicester Planned Care services from 1st April 2014.
7.4.5.3 Implied Efficiency
As part of the base case modelling the Trust has reviewed its resultant implied
efficiency inherent within the current planning assumptions.
The implied efficiency calculation takes into account the impact of the forecast
inflationary pressures assumed on the relevant proportions of the Trust’s cost base to
derive a weighted average efficiency score.
Recent Monitor guidance set out the expectation that the base case efficiency
requirement over the life of the LTFM will be 4% per annum. The exception to this is
for 2015/16, where the requirement is anticipated to be 4.5%.
The Trust has used these assumptions to determine the level of efficiencies required
going forward. These are efficiencies driven by national inflation and cost pressures,
and efficiencies driven by local cost pressures.
The table below summarises the national inflation and cost pressures which drives
the implied efficiency, and provides the total CIP requirement the Trust will need to
deliver each year.
The Trust’s CIP requirement is in excess of the efficiency levels in all years. This is
due to the investment in Staffing for Quality in 2014/15 and the planned increase to
underlying surplus levels from 2015/16 onwards.
Page | 146
2014/15
%
Pay and Prices
Tariff Deflator
Implied Efficiency
CIP Requirement - £000's
CIP Requirement - %
2015/16
%
2016/17
%
2017/18
%
2018/19 2019/20
%
%
2.13
1.80
3.93
2.44
1.60
4.04
3.09
0.68
3.77
2.89
0.60
3.49
2.84
0.70
3.54
2.84
0.70
3.54
7,500
5.20%
7,672
5.00%
6,083
4.00%
6,414
4.20%
6,264
4.20%
6,092
4.20%
Monitor has not issued specific details regarding how they have derived their
efficiency requirements going forward. However, based on a number of assumptions
and by benchmarking with other NHS providers, a sensible assessment can be made
regarding inflationary pressures on payroll and specific non pay lines. These
assumptions can then be applied to the Trust’s cost base to derive an overall
efficiency level.
The table below shows how by applying the “derived” inflationary assumptions to the
Trust’s cost base composition, a DCHS efficiency level can be determined. Whilst
this will not be 100% accurate it serves to provide assurance that the current
assumptions within the new LTFM are robust.
Monitor Assumptions
DCHS (Using Monitor Assumptions)
2014/15
2015/16
2016/17
2017/18
2018/19
2014/15
2015/16
DCHS Actuals as per LTFM
2016/17
2017/18
2018/19
2014/15
2015/16
2016/17
2017/18
2018/19
Income
-1.5
-1.6
0.4
-0.6
-0.7
Income
-1.8
-1.6
0.4
-0.6
-0.7
-1.8
-1.6
-0.68
-0.6
-0.7
Cost
2.55
2.89
4.38
3.38
3.33
Cost
2.22
2.60
4.16
3.13
3.08
2.13
2.44
3.09
2.89
2.84
Net
-4.05
-4.49
-3.98
-3.98
-4.03
Net
-4.02
-4.20
-3.76
-3.73
-3.78
-3.93
-4.04
-3.77
-3.49
-3.54
1.5
2.1
7.2
3.8
2.5
2.5
7.2
3.8
4
3
7.2
3.8
3
3.2
7.2
3.8
3
3
7.2
3.8
1.5
2.1
7.2
3.8
2.5
2.5
7.2
3.8
4
3
7.2
3.8
3
3.2
7.2
3.8
3
3
7.2
3.8
2.0
2.1
4.0
3.8
2.3
2.5
4.0
3.8
2.5
3.0
4.0
3.8
2.7
3.2
4.0
3.8
2.7
3.0
4.0
3.8
Pay
Non-Pay
Drugs
Cost of Capital
Service Development
0.98
0.48
0.50
0.19
0.40
1.63
0.58
0.50
0.19
0.00
2.60
0.69
0.50
0.19
0.40
1.95
0.74
0.50
0.19
0.00
1.95
0.69
0.50
0.19
0.00
1.03
0.54
0.06
0.18
0.40
1.71
0.65
0.06
0.18
0.00
2.74
0.77
0.06
0.18
0.40
2.06
0.83
0.06
0.18
0.00
2.06
0.77
0.06
0.18
0.00
1.37
0.54
0.04
0.18
0.00
1.58
0.65
0.04
0.18
0.00
1.70
0.77
0.04
0.18
0.40
1.85
0.83
0.04
0.18
0.00
1.85
0.77
0.04
0.18
0.00
Cost Inflation
2.55
2.89
4.38
3.38
3.33
2.22
2.60
4.16
3.13
3.08
2.13
2.44
3.09
2.89
2.84
Pay
Non-Pay
Drugs
Cost of Capital
65.0%
23.0%
7.0%
5.0%
100.0%
68.5%
25.8%
0.9%
4.8%
100.0%
68.5%
25.8%
0.9%
4.8%
100.0%
The breakdown demonstrates that the Trust cost structure is different to the
benchmark used by Monitor. The Trust pay costs are around 69% of total costs,
compared to the benchmark of 65%. This is offset by the Trust having a higher level
of non-pay costs at 26% compared to the benchmark of 23%.
However, the main material area of difference is that the benchmark assumes the
cost structure includes 7% for drugs. As a community provider the proportion of our
Page | 147
expenditure on drugs is much lower at less than 1%. As drugs are an area where
inflationary and cost pressures are disproportionately high, our low proportional
spend in this area reduces the expected cost pressure and therefore efficiency
requirement.
The net result is that the Trust’s cost pressure using these assumptions is around
0.5% below the national average in each year of the model.
Where the Trust has differing efficiency assumptions to Monitor, the difference will be
included within the updated downside scenario.
7.4.5.4 CIP Schemes
The planning for CIP schemes for 2014/15 and 2016/17 is now substantially
complete and the plan appropriately reflects the proposed schemes.
The 2015/16 plans include the efficiency savings required to ensure that the service
lines within Health WellBeing and Inclusion are financially viable given the current
assumption about future contractual values once they are market tested.
The table below shows the high level detail supporting the programme for the first
three years of the plan.
Scheme
2014/15
000s
WTEs
2015/16
000s
WTEs
2016/17
000s
WTEs
Adults and Frail Elderly
Health WellBeing & Inclusion
Planned Care - Derbyshire
Corporate Services
Support Services
Other
1,784
981
653
750
2,348
984
11.30
10.59
0.63
15.00
35.48
0.00
3,492
458
650
785
1,296
991
45.45
10.88
5.50
13.86
29.38
0.00
1,327
987
601
914
1,769
485
25.50
27.31
5.74
14.06
28.46
0.00
Total Savings
7,500
73.00
7,672
105.07
6,083
101.07
The main themes underpinning the delivery of the cost improvement plans are as
follows:



Re-skilling of the workforce supported by the People Strategy to ensure staff
skills address patient need
Estate Rationalisation supported by the Estate Strategy
IM&T investment delivering efficiencies around improved productivity, reduced
travel and other overhead costs
Review of current bed capacity and rationalisation where appropriate
Page | 148
Work continues through the Trust’s Project Management Office ensure detailed
project plans underpin each scheme and that progress will be routinely monitored
through the Trust’s existing governance processes.
7.4.6 Cash-flow Plans
The table below sets out the planned utilisation and generation of cash. Based upon
the current financial projections, the Trust’s working capital requirements over the
period of the plan can be funded from internal sources.
2014/15
£000's
Cash Required
Investment in working capital
Capital investment
PDC repaid
Repayment of loan capital
Payment of dividends
Interest Payable
2015/16
£000's
2016/17
£000's
2017/18
£000's
2018/19
£000's
2019/20
£000's
Total
£000's
-5,724
-4,971
-5,951
-4,410
-4,139
-4,294
-29,489
-2,511
-2,615
-2,639
-2,667
-2,648
-2,652
-15,732
-8,235
-7,586
-8,590
-7,077
-6,787
-6,946
-45,221
8,472
572
10,039
436
3,505
11,130
421
12,419
481
651
14,111
222
15,546
307
415
46
63
86
100
129
161
71,717
2,439
4,156
415
585
9,505
14,043
11,637
13,651
14,462
16,014
79,312
Opening Cash Position
11,731
13,001
19,458
22,505
29,079
36,754
34,091
Closing Cash Position
13,001
19,458
22,505
29,079
36,754
45,822
45,822
Funded by:
Operating Cash Flows
Investment in Working Capital
Asset disposals
New PDC Allocations
Interest received
The Trust generates the majority of its cash (£71.7 million) through the EBITDA. This
cash will then be used to fund the payment of dividends to the Department of Health
(£15.7 million) and to fund the capital investment plan (£29.4million). The base case
assumes that the Trust disposes of surplus land on the Walton site during 2015/16.
Initial estimates have been calculated which suggest a market valuation of £3m. The
associated cash receipt has been factored into the base case cash-flow planning.
The capital investment plans require a cash investment of £29.4m from 2014/15
onwards which is excess of the cash generated through depreciation over the same
time frame of £25.03m.
However, the Trust is projecting capital receipts of £4.3m in respect of the sale of
surplus land on the Walton site and the disposal of two core units within the Learning
Disability service in line with proposed service model changes.
Page | 149
In 2014/15, the Trust is due to receive a further tranche of Public Dividend Capital as
match funding from the Department of Health to support the implementation of the
new Patient Administration System (PAS).
The Trust has modelled modest year on year increases to cash balances due to
working capital variations.
The Trust has developed a number of key performance indicators to monitor
improvements in the management of cash. Progress against cash-flow plans is
reported through to the Quality Business Committee through the Treasury
Management Report, and then through to Board in the monthly Finance Report.
Corrective actions are agreed through these meetings when required. The current
level of debtor and creditor days are shown in the table below along with the current
planning assumptions built into the base case regarding the movement on these
metrics over the life of the plan.
The debtor days on NHS debt is low due to the nature of the transaction regarding
contractual payments. For the majority of clinical income invoices are raised on the
1st day of the month with payment being received on the 15 th day. This is standard
NHS practice. This has the result of diluting the number of days when combined with
other NHS debt.
The way that the LTFM calculates Non NHS debtor days skews the overall indicator.
This is due to the way the Trust has modelled some of its income within the LTFM.
The important thing to note is that the current base case plans for an ongoing
reduction in debtor days.
As an NHS Foundation Trust, there will be more flexibility to negotiate extended
credit terms with key suppliers.
Working Capital KPIs - Base Case
14/15
15/16
16/17
17/18
18/19
19/20
NHS Receivables
Days
7.5
7.4
6.8
6.5
6.5
6.5
Non NHS Receivables
Days
21.8
17.8
18.3
19.0
19.0
19.0
Trade Payables
Days
48
48
48
48.0
48.0
48.0
7.4.7 Capital Investment Plans
The table below details the 5 Year Capital Investment plan at current year price
levels and as detailed in the base case and the forecast for the current year. It can be
noted that there is a requirement for significant investment in IM&T infrastructure over
the life of the plan as this is a key enabler underpinning the service models.
Page | 150
Capital Investments
Forecast
Forecast
Forecast
Forecast
Forecast
Forecast
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
£000s
£000s
£000s
£000s
£000s
£000s
IBP Delivery / Other
1,597
1,915
274
1,200
1,060
743
318
2,572
1,082
743
318
3,683
1,109
743
318
1,594
1,137
743
318
1,324
1,128
743
318
1,333
Total
4,986
4,693
5,826
3,764
3,522
3,522
Statutory/ Backlog Maintenance
IM&T Strategy
Equipment
In each of the planning years, the capital expenditure is generally equivalent to in
year depreciation with the following exceptions :
In 2013/14, the Trust was successful in securing some central funding from
the Nursing Technology fund which resulted in the allocation of new Public
Dividend Capital of £185k in 2013/14 and an additional £415k in 2014/15. The
Trust is match funding this investment to support the procurement of a
replacement for the current Patient Administration System ( PAS).

In addition to this in 2014/15, the Trust is planning to incur an additional £300k
to purchase Whitecotes Lane, which adjoins the Walton site. This cash will be
recovered in 2015/16 when surplus land is planned to be disposed of with an
estimated cash receipt of £3m.

As part of the Heanor Hospital Redevelopment scheme, an investment of
£2.5m will be required. This has been phased in 2015/16 and 2016/17. Once
the new facility is operational, the Trust plans to dispose of Heanor Health
Centre, most likely in 2016/17 which will yield a capital receipt of
approximately £200k.
The IM&T strategy provides the detail behind the investment plans as detailed below
but the main themes running through the strategy are:




to contribute to patient safety through high quality and robust information
maximise the use of electronic patient records
support the seamless care for every patient by linking information throughout
the organisation
provide performance management information to support the Performance
Management Framework
providing innovative IT based solutions to facilitate changes in the pathways of
care
In addition to the IM&T investment, the plans include the costs of delivering the
Estate Strategy, routine maintenance of the remaining Estate and the rolling
programme of equipment replacement.
The Trust does not require external financing to fund the Capital plan as sufficient
cash resources are planned to be generated internally.
Page | 151
The Trust has a Capital Planning Group which oversees the implementation of the
Capital programme and reports through to the Quality Business Committee.
Business cases are produced for schemes in line with the Trust’s investment policy.
7.4.8 Balance Sheet Plans
Upon the demise of Derbyshire County PCT, non-current assets to the value of
approximately £76m transferred to the Trust. This was transacted through an initial
transfer order and then two further modification orders.
The Trust is required to account for this transfer under modified absorption
accounting. The transfer is transacted through the retained earnings and revaluation
reserve and not through an allocation of new Public Dividend Capital (PDC).
The Trust is required to account for these assets under merger accounting rules and
will therefore bring the assets onto the books at current net book value and with any
corresponding revaluation reserve.
The Trust commissioned the District Valuer to undertake a review of the current book
values recorded by the Trust. This work was undertaken during 2013/14 with a
valuation date of 31st March 2014 .The resultant changes to current valuations were
reflected in the Trust’s 2013/14 Annual Accounts and the plan as presented here has
been updated accordingly.
The Trust is assuming no borrowing over the lifetime of the model. If the Trust were
to take out a long term loan, it would ensure that a robust business case is
undertaken in line with the Trust Investment Policy (based upon Risk Evaluation of
Investment Decisions guidance), and the requirements of the Compliance
Framework for reporting transactions.
Page | 152
Balance Sheet - Base Case
Forecast Forecast Forecast Forecast Forecast Forecast
2014-15 2015-16 2016-17 2017-18 2018-19 2019-20
£m
£m
£m
£m
£m
£m
Non Current Assets
82.7
80.7
83.6
83.6
84.1
85.0
Current Assets
18.9
25.1
27.4
33.8
41.5
50.5
-13.3
-13.3
-13.4
-13.5
-13.6
-13.8
5.6
11.8
14.0
20.3
27.9
36.7
Provisions - Non Current
0
0.0
0.0
0.0
0.0
0.0
Deferred Income - Non Current
0
0.0
0.0
0.0
0.0
0.0
88.3
92.5
97.6
103.9
112.0
121.7
Public Divided Capital
Retained Earnings
Revaluation Reserve
0.2
69.3
18.8
0.2
72.8
19.5
0.2
77.1
20.3
0.2
82.6
21.1
0.2
90.0
21.8
0.2
98.9
22.6
Total Assets Employed
88.3
92.5
97.6
103.9
112.0
121.7
Current Liabilities
Net Current Assets / Liabilities
Total Assets Employed
Represented By:-
7.5
Sensitivity Analysis
Financial modelling has been undertaken to assess the impact on the base case
scenario of the crystallisation of a number of strategic risks to the delivery of the
Integrated Business Plan.
These are described in detail in section 8.
7.6
Preparation for Foundation Trust Status
The Trust recognises that the financial regime of an NHS foundation Trust is different
to an NHS Trust, and to meet the requirements of the Risk Assessment Framework,
improvements in financial systems have been introduced.
7.6.1 Financial Reporting
The Trust is regularly reviewing the management information it provides to ensure it
meets the needs of the audience. The Board and Quality Business Committee
finance reports have been reviewed and amended in April 2011, October 2011 and
March 2012 to reflect the changing maturity and needs of these meetings.
Page | 153
Following the introduction of a new Treasury Management Policy, a number of KPIs
have been introduced around working capital. These are routinely reported to the
Quality Business Committee, which provides assurance that actions agreed are
leading to improvements in working capital management. This has proven useful in
getting a better understanding of the drivers of the working capital position. The
Treasury Management Report was revised in July 2012 by introducing a Treasury
management dashboard.
Cost improvement programme reporting has been strengthened to take into account
best practice guidance issued by Monitor and the Audit Commission, and to take on
advice provided by PwC and KPMG from their reviews of Historical Due Diligence
and the Board Governance Assurance Framework respectively. The new reporting
was put in place for May 2012.
The Trust has introduced Business Intelligence which is providing more real time
information. This now allows the finance report to be supplemented with verbal flash
reports on in year activity performance.
7.6.2 Service Line Reporting
The Trust has a costing system which allows it to produce service line financial
reports. These reports are produced on a quarterly basis, and provide managers,
clinicians and the Board with information around the relative profitability of service
lines.
The Trust has recognised that it needs to move forward its use of service line
reporting, and commissioned Assista Consulting to undertake a review of our costing
processes. A development plan has been agreed, and this is being taken forward
with continued support from Assista
7.6.3 Financial Governance
The Trust has established a Quality Business Committee. One of the roles of this
committee is to scrutinise the financial position of the Trust and report any concerns
or issues through to the Board.
The Trust has recently reviewed its Standing Orders and Standing Financial
Instructions. An annual review is scheduled on the forward agenda of the Board.
A number of new policies have been introduced into the Trust in readiness for
Foundation Trust status.
The Treasury Management Policy sets out how cash will be monitored, and is based
upon Monitor best practice guidance. The Trust now reports routinely through to the
Quality Business Committee around a set of key performance indicators, and has
started to “shadow invest” to prepare for investing surplus cash when foundation
Trust status is achieved.
The Investment Policy sets out the governance process for all investments (excluding
cash). It is based upon Monitor best practice guidance “Risk Evaluation for
Page | 154
Investment Decisions in Foundation Trusts”. This policy provides the basis for the
Trust to use the additional freedoms to invest when foundation Trust status is
achieved.
The Trust has established a Project Management Office structure whose key remit is
to oversee the implementation of the Integrated Business Plan, including the delivery
of change programmes that will deliver cost improvements. Each programme has an
Executive Sponsor. Progress against the plans is reported through to the Quality
Business Committee. The Trust has commissioned an external review of the
Programme Management Office. This was conducted by PwC in July 2012, and the
Trust has implemented the recommendations identified within this review
7.6.4 Financial Capacity and Capability
The Trust has a strong record of delivering its financial duties, and has an
experienced finance team who has consistently delivered high quality financial
advice. However, the Trust recognises that the financial regime in a foundation Trust
is different to that of an NHS Trust, and that existing staff will need to be developed
to equip them to operate in this environment.
The Finance team has operated independently of the PCT Finance team for a
number of years. The management accounting function has been separate since
April 2008 and the Financial Management team from April 2009.
The Finance Team consists of approximately 30 WTEs. There are no current
vacancies. Whilst the majority of the staff in post are permanent, the department is
currently running with a number of temporary staff. The number of CCAB qualified
staff is 7, with another 5 part-qualified; AAT qualified number 12 with a further 3 partqualified. All staff are encouraged to undertake some form of Finance study
The Trust has strengthened the finance function recently through recruiting senior
staff with foundation Trust experience. The Trust has appointed an experienced
Director of Finance, Performance and Information who has led a finance function
through the application process and operated in the foundation Trust environment for
4 years. The Trust has also appointed an experienced accountant from a foundation
Trust to lead the Treasury Management function and an experienced accountant
from a foundation trust to lead on major projects and tenders.
Regular finance department “time-outs” are being arranged to conduct specific
training for staff, as well as routine training through external providers such as the
Healthcare Financial Management Association (HFMA).
Key points of this section:




The Trust has a record of achieving financial targets
The financial plans have been developed on the basis of a set of realistic
assumptions
The financial plans forecast a Continuity of Services rating of 4 in all years
A surplus of at least 1% of turnover is planned every year
Page | 155
Page | 156
8
Risks
Purpose of this section:
 Describe the key risks facing DCHS;
 Describe the potential impact and mitigating action of the risks;
 Identify the financial risks and model against base case identifying a series
of sensitivities.
8.1
Summary of Key Organisational Risks
For DCHS to achieve its vision and objectives the organisation has to have the
capability to develop and deliver its strategic plans, and deal with the internal and
external factors that it faces which affect achievement of these plans. Key to this is
the ability for DCHS to understand and develop mitigation plans in response to the
key risks, and implement these quickly and effectively.
The approach to risks throughout DCHS is based upon the aggregation of risk from
the front line to the Board, this is known as the ‘Top X’ approach. The main aim of
risk management within DCHS is to identify the events that would reduce the
certainty of achieving one or more objectives and establish processes to manage
those risks - regardless of whether the risk exists at a financial, strategic, clinical or
operational/business level.
The organisation has identified a number of major strategic risks relating to its
operations, these areas have control systems in place and are reflected in the Board
Assurance Framework (BAF).
The application of controls and assurances highlight specific areas of risk at any
particular time, informed by the operational risk register, and subject to specific
focused management action. Key areas within each strategic risk are addressed in
this IBP and supporting strategies, and are summarised below (as of beginning May
2014):
Page | 157
QUALITY SERVICE
Risk to Quality – failure to consistently deliver a safe, effective service to
patients and clients, with associated risks of harm to patients, regulatory,
reputational and financial consequences.
Area/s of risk
Risk Impact
There is a risk
to patients due
to exposure to
unsafe care
Patients
suffer
avoidable
harm whilst in
the care of
DCHS
Mitigation






There is a risk
to Patients due
to clinical
records not
meeting
national
standards
Poor quality
clinical
records do
not allow for
the effective
treatment and
care of


Patient Safety
Thermometer
continues to be core
instrument for
assessment and
measurement
Clinical Quality
Metrics and KPIs
identified and will be
reported through
Board performance
reports
Rapid response
Indicators identified
and incorporated into
live dashboard
CQuIN focus on
pressure ulcer
reduction
Specialist teams in
place to support
Tissue viability,
Infection Prevention
and Control and
Catheter care
Falls and TV
strategies in place
DCHS expects staff
to follow Professional
Codes of Conduct in
relation to record
keeping
Standardised records
and associated
training available to
all relevant staff
Page | 158
Director Lead
Current
risk
rating
Director of
Quality / Chief
Nurse
10
Director of
Quality / Chief
Nurse
12
patients



There is a risk
to patients due
to failure to
provide
services that
are clinically
effective and of
high quality
Patients are

harmed or
have care
resulting in no 

benefit


There is a risk
that patients
do not get
optimal care
due to the
Priority Clinical
Audit
Programme for
the Trust not
being
appropriately
focused and
effective
Improvements 

in clinical
areas aren’t
realised
resulting in
poor
outcomes for
patients
There is a risk
to the
organisation
during the
implementation
of changes to
our Quality
Ineffective
reporting and
assurance on
quality



Regular record
keeping audits with
staff involved in
action planning for
improvement
New patient care
records have been
implemented to drive
a more patient focus
Continuation of roll
out to System one
TPP
Clinical Audit Priority
Audit Plan
Director of
Quality / Chief
Nurse
10
Director of
Quality / Chief
Nurse
12
Director of
Quality / Chief
Nurse
12
NICE Guidelines
Clinical Policy
approval process
PGD approval
process
CQUIN Goals &
Quality Schedule
Requirement
Clinical Audit strategy
Improved focus on
clinical audit and
associated learning
Quality improvement
and assurance
framework
Clinical effectiveness
and audit programme
staff training and
development
Page | 159
Assurance
processes
There is a risk
to the
organisation
due to noncompliance of
administration
of the MHA
1983
Poor patient
outcomes and
breaches in
legislation

Quality Schedule
(Contract) with
Commissioner

AMHAM Audits

MCA & DoLS Activity
report
Safeguarding reports


Director of
Quality / Chief
Nurse
12
Regular training
updates for staff
QUALITY PEOPLE
Risk posed by People – failure to maintain a high performance work
environment that positively supports and engages people to fulfil their
potential, with the right people, with the right skills in the right places.
Area/s of risk
Risk Impact
There is a risk
to patients due
to Staff not
being
appropriately
trained to
provide high
quality care
Poor patient
outcomes.
There is a risk
to patients due
to staff
performance
not being
monitored and
improved
Poor patient
outcomes.
Mitigation








Director Lead
Current
risk
rating
Robust appraisal
process
Essential Learning
program
Monthly performance
reports
Induction program
Compliance Matrix
through ESR
Director of
People and
Organisational
Effectiveness
10
Appraisal process
Quarterly
Performance review
cycle
Clinical Supervision
process
Director of
People and
Organisational
Effectiveness
10
Page | 160



Stay Safe campaign
Essential training
H&S Policy.
Director of
People and
Organisational
Effectiveness
12
Poor patient
outcomes.

Monthly performance
reports
People Strategy
Director of
People and
Organisational
Effectiveness
15
Staff become
disengaged
from the
change which
is necessary.

Director of
Board level action re
maintaining positive
People and
engagement through Organisational
major change
Effectiveness
Focus on leadership
development across
Trust
Engagement strategy
in place
Staff survey results
for 2012/13 suggest
engagement levels
are being maintained.
Director of
Workforce Planning
process
People and
Project Management Organisational
Office
Effectiveness
Organisational
Development system
People Strategy
10
There is a risk
to staff due to
lack of
ownership and
inadequate
management
of Health &
Safety
Staff (plus
patients and
visitors)
injury.
There is a risk
to patients due
to the
organisation
not being able
to attract and
retain qualified
staff with the
right
behaviours to
work in the
right locations
There is a risk
to organisation
due to the loss
of staff
engagement
Breach of
legislation



Poor patient
outcomes.
There is a risk
to organisation
due to poor
change
management
adverse
impact upon
ability of Trust
to implement
future plans





There is a risk
to the
not meeting
our legislative

Equality, Inclusion
and Human Rights
Page | 161
Director of
People and
9
10
organisation in
the failure to
effectively
embed
equalities good
practice across
all aspects of
DCHS'
business,
duties under
the Equalities
Act 2010 and
the
requirements
of the NHS
Equality
Delivery
System
There is a risk
to the whole
organisation
due to not
attracting,
recruiting and
retaining a
diverse
workforce.
inability to
achieve our
aspiration to
achieve a
representative
workforce and
services that
meet people's
needs, meet
our legislative
duties under
the Equalities
Act 2010 and
the
requirements
of the NHS
Equality
Delivery
System (EDS)
Strategy
Organisational
Effectiveness
Equality, Inclusion
and Human Rights
Strategy
Induction / Probation
Process
Director of
People and
Organisational
Effectiveness



10
QUALITY BUSINESS
Risk posed by Business Strategy – failure to understand and address
competitive pressures in changing environment, resulting in loss of business,
or inability to deliver service changes required due to failure in identifying and
managing policy, political and stakeholder context.
Area/s of risk
Risk Impact
There is a risk
to the
organisation
Poor
outcomes
across the
Mitigation

IBP

LTFM
Page | 162
Director Lead
Current
risk
rating
Director of
Strategy
10
achieving
strategic
objectives due
to a lack of
integrated
planning
There is a risk
to the
organisation
due to loss of
business as a
result of not
actively
managing the
more
competitive
environment
There is a risk
to delivery of
the IBP due to
change in
commissioner
priorities
DCHS Way
Financial loss
Financial loss

Annual Plan

Annual Plan updates


Performance Reports
PMO reports

Contract report

Business
Development
Reporting

Commercial Strategy

Business
development
framework (e.g.
investment policy /
decision making tool)

Competitor and
market analysis

Tender oversight and
analysis
Contract
management and
negotiation process



There is a risk
to the
organisation
due to failure
impact upon
future
demand for
Director of
Strategy
12
Director of
Strategy
15
Director of
Strategy
10
Executive team
meetings with
Commissioner Chief
Officers / teams
Analysis of
commissioning
intentions as part of
planning process

CIP plans indicate
level of commissioner
support

Communications and
marketing strategy

Board level lead for
communications and
Page | 163
to maintain a
positive
reputation
services


marketing
Staff and service
user friends and
family test
Staff survey
Risk posed by Business Finance – failure to deliver financial plans and
maintain a financially viable and sustainable organisation.
Area/s of risk
Risk Impact
There is a
risk to the
organisation
due to the
inability to
meet
financial
targets,
specifically
cost
improvement
plans, as set
out in Annual
Plan and IBP
Financial risk
and
reputational
damage.
There is a
risk to the
organisation
due to poor
decisions
being made
due to poor
data quality
resulting in
poor outcomes
and financial
loss
Mitigation
Director Lead
Current
risk
rating
Financial Control System
Director of
Finance,
Performance
and
Information
10
Director of
Finance,
Performance
and
Information
12


Finance Reports
CIP Reports

LTFM

Treasury
Management Reports

Data Quality Control
System

Performance
Reporting - Data
Quality issues
Data Quality Kite
mark
Policies and
procedures


Business Infrastructure – failure to manage key areas of enabling
infrastructure change to support service strategies
There is a
risk to the
organisation
Poor patient
outcomes.


Capital Planning
System
Progress Reports
against Estates
Page | 164
Director of
Operations
12
due to poor
estate
impacting
upon patient
care
Unsafe
environment in
which to work
There is a
risk to the
organisation
due to
variable site
utilisation
There is a
risk to the
Trust’s
activities, due
to an
emergency
or severe
disruption

Strategy
Planned Preventative
Maintenance System

Policies and
procedures
Inefficient use
of resources

Capital Planning
System
Progress Reports
against Estates
Strategy
Director of
Operations
9
Impact on
patient care.

Director of
Operations
10
inability to meet
targets, loss of
revenue

EPRR Control
System
Accountable
Emergency Officer
appointed
Major Incident
Plan/Business
Continuity Plan




Site Contingency
Plan in-place
Pandemic
Influenza
Contingency Plan inplace
Internal assessment
against NHS
England's Core
Standards for EPRR
undertake
GOVERNANCE
Risks posed by Governance – failure to develop and maintain effective
governance systems that underpin long term success and support the
control/assurance systems developed to mitigate against key strategic risks
Area/s of risk
There is a
risk to the
organisation
Risk Impact
Trust vision not
being delivered
Mitigation

Corporate
Governance Manual
Page | 165
Director Lead
Current
risk
rating
Trust
Secretary
10

due to not
having strong
corporate
governance
systems in
place









There is a
risk to the
organisation
due to not
meeting
regulatory,
contractual or
legal
obligations
External
sanctions
against the
Trust.



Board Committee
Reporting
Quality Governance
reporting
Internal Audit
Reports
Counter Fraud
Reports
External Audit
Reports
Scheme of
Delegation
Self-Certification
Reporting
Board Assurance
Framework
Clinical Audit
Programme
Annual Governance
Statement
CQC Compliance
Reporting
Shadow Monitor SelfCertification
Performance
Reporting
Trust
Secretary
10
Poor
patient/staff
outcomes.
Financial loss.
8.2
Sensitivity Analysis
8.2.1 Introduction
The Integrated Business Plan (IBP) sets out the Trust plans for the next 5 years. The
financial plan has been developed based on a set of realistic assumptions that have
been discussed by the Board. These assumptions have been benchmarked with
other organisations, and work has been undertaken to sense check the outputs.
Page | 166
Under the current set of assumptions, the model provides a realistic outlook of the
finances of the organisation for the next 5 years.
However, the Trust operates in a dynamic environment. The Trust will need to
demonstrate that it has reviewed the robustness of the financial model to a number of
additional financial pressures that could realistically materialise, and that the Trust
has plans to mitigate against these risks. This is the downside scenario.
The downside scenario will consist of two elements:


Changes in areas where the assessor believes the Trust has been over
optimistic in its base case assumptions
Additional downsides to stress test the robustness of the organisations
finances should the financial climate deteriorate.
The base case of the Trust will be reviewed and any areas where the assessor
believes the Trust has been over optimistic will result in changes being modelled
through. This results in the Assessor case. It is the assessor case which is then
tested with a downside scenario.
This section reviews the financial base case in three areas:


Trigger points for Continuity of Service (COS) and the Financial Risk Ratings
(FRR) to understand what financial impact is required to change the rating,
and through which metrics
An initial Trust Downside scenario consisting of a set of realistic adverse
sensitivities (derived from the risk section), then mitigated by Trust actions
From this analysis the Board will be in a position to assess whether the Trust is
financially viable under a realistic downside scenario.
This section provides a summary of the Trust downside plan.
8.2.2 Sensitivity of the Model to Changes in the Risk Rating
It is important to understand the sensitivity of the base and the level of headroom
available before a deterioration in the overall ratings would occur.
Based on the current model, a reduction to EBITDA margin in 2014/15 of £4.6m
would result in a reduced score of the capital servicing metric and an overall drop on
to a COS rating of a 3. A further reduction in margin of £1.5m would impact on both
metrics sufficiently to reduce the overall COS rating to a 2.
In 2014/15 a reduction in margin achieved of £5m would result in the overall FRR
scoring a 2 due to the I&E margin dropping to a 1 thereby limiting the overall score to
a 2.
8.2.3 Sensitivity of the Model to a Multiple Downside Scenario
Page | 167
8.2.4 Trust Downside Case
This is an initial Trust downside case is based upon Trust specific risks from the risk
section. The following variations from the base case have been included:




Increased recurrent efficiency to match Monitor implied efficiency assumptions
Increase recurrent efficiency of 0.5% per annum as per Monitor downside
Non achievement of CIP in a phased way - 10% non-recurrent slippage each
year and 15% recurrent underachievement.
Loss of a service line without a corresponding reduction to the Trust’s cost
base
It is important that the Trust understands the impact of this scenario on both the
Continuity of Service (COS) rating and the Financial Risk Rating (FRR) methodology.
The impact of this scenario is shown in the tables below:COS Rating
Continuity of Service Rating
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
Liquidity - Rating
4
4
3
1
1
1
Liquidity - Value
9.80
4.20
-6.70
-29.50
-49.50
-71.20
Capital Servicing - Rating
3
1
1
1
1
1
Capital Servicing - Value
1.90
-0.30
-0.60
-1.20
-1.50
-1.90
4
3
2
1
1
1
Overall COS Rating
Under the COS rating system, in 2014/15, the overall rating remains at a 4 although
inevitably the scores on the metrics fall due. From 2015/16 under the Trust’s
downside scenario, the COS suffers a year on year reduction due to falling EBITDA
margins reducing the Trust’s ability to cover its capital servicing costs. In addition the
cumulative impact of this on the cash resources available drive the liquidity score
down. Without any mitigating actions being taken, the overall rating falls to a 1 in
2017/18. This is the minimum score that can be achieved.
The table below shows the impact of the same scenario on the Trust’s performance
against the FRR rating system.
Financial Risk Ratings - TRUST DOWNSIDE CASE
Metric
EBITDA margin
EBITDA, % achieved
ROA
I&E surplus margin
Liquid ratio
2014-15
3.00%
77.80%
2.10%
-1.10%
37.1
2
3
2
2
4
2015-16
-0.60%
77.80%
-9.20%
-4.90%
31.3
1
1
1
1
4
2016-17
-1.10%
-15.00%
-11.40%
-5.40%
19.8
1
5
1
1
3
2017-18
-1.90%
-24.90%
-15.40%
-6.30%
(3.9)
1
5
1
1
1
2018-19
-2.50%
-28.20%
-19.60%
-6.80%
(24.1)
1
5
1
1
1
2019-20
-3.10%
-33.00%
-26.30%
-7.20%
(46.4)
1
5
1
1
1
Weighted Average
2.50
1.75
1.90
1.40
1.40
1.40
Overall FRR
2.00
1.00
1.00
1.00
1.00
1.00
Page | 168
It is important to note that whilst the performance against this methodology also
demonstrates deterioration, it is more severe due to the increased emphasis on
EBITDA margin and surplus levels. Under this system and without any mitigating
actions being taken, the Trust would revert to an FRR of a 1 in 2015/16. This rapid
fall in performance is driven by the assumption within the Trust downside case
regarding the loss of a service line and its associated income and the cumulative
impact of CIP slippage. The downside case assumes that the Trust is unable to
release any costs associated with the decommissioned service and therefore
margins are significantly reduced. The Trust’s rating would fall to the minimum that
can be achieved in 2015/16. This compares to a COS score of a 3 in 2015/16.
In summary, whilst under both systems, the downside scenario would have a
significant impact on the overall rating performance, the Trust’s strong liquidity
position within the base case, provides an element of headroom under the COS
ratings when compared to the FRR methodology.
The table below shows the impact of Trust’s downside scenario on cash and surplus
levels.
SURPLUS
2015/16
2016/17
2017/18
2018/19
2019/20
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
£m
£m
£m
£m
£m
£m
£m
£m
£m
£m
£m
£m
Trust Base Case
2.00
3.44
4.38
5.56
7.29
8.98
13.00
19.46
22.50
29.08
36.75
45.82
Additional 0.5% CIP required each year
-0.82
-1.60
-2.38
-3.24
-4.09
-4.96
-0.82
-2.43
-4.81
-8.05
-12.14
-17.10
10% slippage on all CIP schemes
-0.75
-0.80
-0.64
-0.71
-0.71
-0.72
-0.75
-1.54
-2.18
-2.77
-3.48
-4.21
15% recurrent non-achievement
-1.13
-2.27
-3.20
-4.18
-5.14
-6.07
-1.13
-3.41
-6.58
-10.09
-15.08
-21.01
Loss of income from service line
Downside Case
CASH
2014/15
0.00
-4.43
-4.39
-4.40
-4.37
-4.33
0.00
-4.42
-8.83
-13.15
-17.52
-21.85
Additional efficiency to meet Monitor expectations
-1.10
-1.84
-2.22
-3.08
-3.90
-4.75
-1.10
-2.95
-5.16
-8.25
-12.14
-16.89
Trust Downside Case Before Mitigation
-1.80
-7.50
-8.45
-10.06
-10.93
-11.86
9.20
4.72
-5.06
-13.23
-23.61
-35.22
The deterioration year on year in the EBITDA margins achieved are a result of the
cumulative impact of the increased efficiency requirements and reduction in CIP
delivery and loss of income over the base case which is not mitigated against.
Due to the reducing margins, there is a significant outflow of cash resulting in a deficit
of £35.2million by the end of the model. The deficit position reaches £11.9 million by
2019/120.
8.2.4.1 Mitigating Action
The mitigation plans that have been developed are both generic and specific. The
Trust has plans that can be introduced quickly to mitigate the immediate short term
issue and risk. In the medium term, it is likely that more specific measures will be
required.
The Trust has developed its mitigation plans. These plans include a range of
measures which would be reviewed dependent upon the specific circumstances
being mitigated.
A number of assumptions have been made regarding elements of the mitigation plan
to demonstrate the value of the mitigations that would be required under the
Page | 169
downside scenario to preserve margins and cash and to ensure that the Trust
maintains adequate scores against both financial rating methodologies.
8.2.4.2 Short term plans
The Trust will not be able to implement major change in the short term. It will
therefore need a range of measures to generate cash to give the time to put the
medium term measures in place. The short term measures will be generic and have a
number of themes:
Measures introduced to improve the income and expenditure position will also have a
cash impact. Immediate measures to be introduced include:



Deployment of Uncommitted Reserves held for downside risks
Stopping of discretionary spend
Stop / Delay non critical capital expenditure
These measures would generate short term revenue and cash to generate time for
medium term measures to be introduced, and to generate cash to invest to ensure
the change happens.
8.2.4.3 Medium Term Measures
The short term plans will provide the Trust with time to implement the medium term
plans, and cash to fund any restructure costs required. The medium term plans will
take some time to mobilise. However, these plans will be incorporated into the
Project Management Office structure so that the Trust can be as prepared as
possible when the need arises. It is also planned that some of these mitigation plans
will be implemented as cost improvement plans when the time is right, and greater
confidence as to their achievability has been provided.
Medium term measures would be more specific to the risks they are addressing. The
measures to be reviewed include:




Service decommissioning – attack costs associated with the service being
decommissioned
Rationalisation of Estate
Review of terms and conditions including increments
Introduce and review charging i.e. car parking, catering prices etc.
These measures will be reviewed regularly in the mitigation plan. The revenue
impact of these measures is summarised below. The phasing of these measures is
flexible as long as there is sufficient lead time to plan the changes.
Page | 170
Indicative Saving
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
£000s
£000s
£000s
£000s
£000s
£000s
Decommissioned Services
Estate Reconfiguration
Car Parking Charges
Stop paying increments
0
0
0
0
3,800
0
0
0
3,800
0
0
0
3,800
500
500
0
3,800
500
500
1,190
3,800
500
500
1,250
0
3,800
3,800
4,800
5,990
6,050
8.2.4.4 Mitigated Scenario
Under the Trust downside scenario, the mitigated position results in a COS rating of
a 4 in 2014/15 and a rating of a 3 in all other years of the model. This reflects the
relatively stronger performance of the Trust’s underlying base case model against the
COS rating when compared to the previous FRR methodology.
8.2.4.5 Impact upon Continuity of Service Rating
COS Rating
Continuity of Service Rating
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
Liquidity - Rating
4
4
4
3
3
2
Liquidity - Value
9.80
5.60
5.90
-3.20
-6.40
-9.40
Capital Servicing - Rating
3
2
2
2
3
3
Capital Servicing - Value
1.90
1.40
1.70
1.60
1.80
1.90
4
3
3
3
3
3
Overall COS Rating
In all years except 2014/15, the Trust’s COS rating recovers to a 3. This is the
minimum requirement to achieve Foundation Trust status.
8.2.4.6 Impact upon Financial Risk Rating
The successful implementation of the mitigation plan would mean that the FRR would
recover to a 2 in all years of the model as shown in the table below. This compares to
a COS rating of a 3.
Financial Risk Ratings - TRUST DOWNSIDE CASE MITIGATED STAGE 1
Metric
EBITDA margin
EBITDA, % achieved
ROA
I&E surplus margin
Liquid ratio
2014-15
3.00%
77.80%
-3.70%
-2.00%
33.5
2
3
2
2
4
2015-16
2.30%
77.80%
-3.70%
-2.00%
33.5
2
3
2
2
4
2016-17
2.70%
39.30%
-2.90%
-1.50%
33.4
2
1
2
2
4
2017-18
2.70%
34.20%
-3.40%
-1.70%
23.9
2
1
2
2
4
2018-19
3.00%
33.90%
-2.80%
-1.30%
20.4
2
1
2
2
4
2019-20
3.10%
33.20%
-2.00%
-0.90%
17.1
2
1
2
2
4
Weighted Average
2.60
2.60
2.40
2.40
2.40
2.40
Overall FRR
2.00
2.00
2.00
2.00
2.00
2.00
Page | 171
8.2.4.7 Impact upon Surplus and Cash
The table below details the impact of the mitigation plans on both the surplus and
cash position:
SURPLUS
2015/16
2016/17
2017/18
2018/19
2019/20
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
£m
£m
£m
£m
£m
£m
£m
£m
£m
£m
£m
£m
-35.22
Trust Downside Case
Trust Downside Case
CASH
2014/15
-1.80
-7.50
-8.45
-10.06
-10.93
-11.86
9.20
4.72
-5.06
-13.23
-23.61
Release of Downside Contingency
0.00
0.00
1.58
2.00
2.00
2.00
0.00
0.00
1.58
3.50
5.50
7.50
Stop Discretionary Spend
0.00
0.52
0.51
0.55
0.56
0.57
0.00
0.52
1.02
1.56
2.13
Delay Capital Expenditure
0.00
0.00
0.00
0.00
0.00
0.00
0.50
1.02
1.50
2.00
2.50
Release costs of decommissioned service line
0.00
3.89
4.04
4.17
4.28
4.40
0.00
3.89
7.93
12.10
16.38
Estates rationalisation
0.00
0.00
0.00
0.56
0.57
0.59
0.00
0.00
0.00
0.56
1.00
Car Parking charges
0.00
0.00
0.00
0.54
0.56
0.58
0.00
0.00
0.00
0.54
1.00
Stop paying increments
0.00
0.00
0.00
0.00
1.19
2.44
0.00
0.00
0.00
0.00
1.19
2.50
3.00
20.78
1.50
1.50
3.62
Other effects through the model
0.00
0.03
-0.04
-0.45
-0.38
-0.26
0.00
0.04
0.02
-0.77
-0.91
-0.72
Trust Downside Case - Mitigated
-1.80
-3.06
-2.36
-2.69
-2.15
-1.54
9.70
10.18
7.00
6.27
5.18
4.46
Due to the severity of the downside, the Trust has to take the following action:





Release contingencies
Delay capital investment plans
Undertake further estate reconfiguration
Offset loss of income through reducing associated cost
Stop paying increments in 2018/19
The cumulative value of the mitigating actions by the end of the model is
£10.58million in revenue terms and £40.4million in cash terms
The table below details the additional mitigations that would be required to bring the
COS rating to a 4. However, additional mitigations would need to be identified that
further improve margins to ensure that the FRR would recover sufficiently to achieve
a 3. A further set of mitigations of £1.4m from 2014/15 and an additional £1.5m from
2016/17 would be required to return to a FRR of 3 in all years.
SURPLUS
Trust Downside Case
Trust Downside Case
CASH
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
£m
£m
£m
£m
£m
£m
£m
£m
£m
£m
£m
£m
-1.80
-7.50
-8.45
-10.06
-10.93
-11.86
9.20
4.72
-5.06
-13.23
-23.61
-35.22
Release of Downside Contingency
1.50
1.50
1.58
2.00
2.00
2.00
1.50
3.00
4.58
6.58
8.58
10.58
Stop Discretionary Spend
0.00
0.52
0.51
0.55
0.56
0.57
0.00
0.52
1.02
1.56
2.13
Delay Capital Expenditure
0.00
0.00
0.00
0.00
0.00
0.00
0.50
1.02
1.50
2.00
2.50
Release costs of decommissioned service line
0.00
3.89
4.04
4.17
4.28
4.40
0.00
3.89
7.93
12.10
16.38
Bfwd CIP Plans
0.00
0.50
0.50
0.50
0.50
0.50
0.50
0.00
0.50
1.00
1.50
Vacancy Management
0.20
0.30
0.30
0.30
0.30
0.30
0.20
0.50
0.80
1.10
1.40
Stop Non Clinical Agency
0.00
0.20
0.20
0.20
0.20
0.20
0.00
0.20
0.40
0.60
0.80
Reduce Non essential estate work
0.00
0.10
0.10
0.10
0.10
0.10
0.00
0.10
0.20
0.30
0.40
Estates rationalisation
0.00
0.00
0.00
0.56
0.57
0.59
0.00
0.00
0.00
0.56
1.00
Car Parking charges
0.00
0.00
0.00
0.54
0.56
0.58
0.00
0.00
0.00
0.54
1.00
Stop paying increments
0.00
0.00
0.00
0.00
1.19
2.44
0.00
0.00
0.00
0.00
1.19
2.50
3.00
20.78
2.00
1.70
1.00
0.50
1.50
1.50
3.62
Other effects through the model
0.00
0.08
-0.05
-0.39
-0.29
-0.15
-0.50
0.59
0.59
-0.27
-0.28
0.02
Trust Downside Case - Mitigated
-0.10
-0.41
-1.27
-1.52
-0.96
-0.33
11.41
14.53
12.47
12.84
12.99
13.48
Page | 172
The impact of the COS rating is shown in the table below. In all years a rating of 4 is
achieved.
COS Rating
Continuity of Service Rating
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
Liquidity - Rating
4
4
4
4
4
4
Liquidity - Value
9.90
9.80
16.20
9.50
8.90
8.40
Capital Servicing - Rating
4
3
3
3
3
3
Capital Servicing - Value
2.50
2.40
2.10
2.00
2.20
2.40
4
4
4
4
4
4
Overall COS Rating
8.2.5 Governance
8.2.5.1 Governance Process
The downside plan has been developed to mitigate against potential future financial
pressures not anticipated within the base case financial model.
It is important that the mitigating actions are mainstreamed into the operations of the
organisation in the same way as planned cost improvement plans to ensure that
schemes can be implemented as soon as possible when the need arises, and to give
confidence that there is substance behind the schemes.
The mitigation plans will be put through the Programme Management Office, and will
be required to be reviewed against the same rigour as cost improvement schemes.
8.2.5.2 Quality Impact Assessments
The Trust will ensure that measures introduced do not adversely impact upon the
quality of service provided. The PMO includes a process whereby all proposed
schemes have to have a QIA, and the scheme will not be progressed until this is
signed off by the Medical Director and Director of Quality / Chief Nurse.
8.2.5.3 Trigger Points
There needs to be a clear rationale for the implementation of the mitigation plan. It
needs to be implemented in a managed and consistent way to ensure minimal
disruption to the organisation.
Page | 173
The Trust has therefore agreed a set of trigger points which should be used as an
early warning system to identify risks. Once these risks are identified there would
need to be a full discussion of the issues to determine if the mitigation plan should be
implemented, and if so, what elements of the plan.
The triggers introduced are forward looking so that any adverse issues are
anticipated proactively, rather than the Trust reacting. This also allows the Trust the
maximum time to implement mitigation plans.
When these trigger points are activated, the Quality Business Committee will need to
seek assurance that mitigation plans are in place to address the risk identified. If the
Committee is assured, then there would be no need to activate formal the mitigation
plan.
However, where a number of trigger points are activated, it will give the Committee a
view of a number of combined risks which together may indicate future financial
problems if the issues are not addressed. At this point, the Committee may determine
that the mitigation plan needs to be implemented, and therefore highlight the
concerns to the Board for a full Board discussion.
8.2.5.4 Assurance
The Programme Management Office is overseen by the Programme Board. This
Board is chaired by the Chief Executive, and has all members of the Executive Team
as members.
Progress against the cost improvement schemes, and mitigation plans, will be
routinely reported through to the Programme Board, and then through to the Quality
Business Committee for additional scrutiny.
The Quality Business Committee will report progress through to the Board, and will
escalate issues for resolution where necessary.
Key points of this section:



DCHS has identified and understands the key risks facing the achievement
and delivery of the IBP.
DCHS understands and has mitigation plans in place to reduce impact of
risks.
Under this analysis, the DCHS can demonstrate that it is financially viable
under a realistic downside case
Page | 174
9
People and Organisational Effectiveness
Purpose of this section:

Describe the senior management arrangements within DCHS;

Describe the workforce profile within DCHS;

Describe the workforce transformation programme;

Describe the DCHS People Strategy – Quality People, The DCHS Way.
Employee engagement will be crucial as we implement new service models,
transform our workforce and introduce new technology and agile working to increase
productivity. The Trust is very proud of the of its track record successful delivery of
change and the year on year improvement in our staff survey results positioning
DCHS as the top specialist community Trust nationally as a place to receive
treatment and to work.
Section 9 outlines the main workforce characteristics of the Trust, in particular that it
is primarily female, with 63% of positions being part-time, it has 52% of employees in
the age range of 46 years and over, low turnover at 9.74% and good attendance at
around 95.99% (during 203/14).
A workforce transformation programme has been developed as part of the IBP to
support the service developments through a range of measures described in detail in
this section. This sets out the workforce and employment transition to deliver
integrated services working with health and social care partners.
DCHS has developed ‘Quality People, The DCHS Way’ a new five year People
Strategy having completed the 2012 -2017 People Strategy two years ahead of plan.
This new strategy sets out how we will further embed the DCHS Way through three
core themes Attract, Grow and Retain, and Engage underpinned by key focus
areas and three strategic priorities – the key ingredients to ensuring DCHS is a high
performing Foundation Trust and truly a great place to work. The strategy supports
the delivery of the IBP and our five year workforce plan.
We are commencing a quality and continuous improvement programme that will
require sustained excellence in organisational development and service
improvement. This all links to and emphasises the critical importance of effective
leadership in delivering an IBP of this magnitude. Our plan outlines our approach to
leadership development at all levels of the organisation, and how important the
Page | 175
health and wellbeing, the recognition and engagement of our staff teams are in
delivering our vision and values for our patients and staff.
Quality Services, Quality Business and Quality People are at the heart of how DCHS
operates; The DCHS Way. DCHS is making strides in becoming a great place to
work and the progress has been made to increase employee involvement and
engagement and is acknowledged by our ongoing improvements in the national staff
survey and tracked quarterly in our internal staff pulse check survey.
We have just developed a new People Strategy - Quality People, The DCHS Way
which sets out how we will further embed the DCHS Way through three core themes
Attract, Grow and Retain and Engage underpinned by key focus areas and three
strategic priorities – the key ingredients to ensuring DCHS is a high performing
Foundation Trust and truly a great place to work. The strategy supports the delivery
of the IBP and our five year workforce plan.
We are working with in partnership with health and social care colleagues to
transform the way services are delivered to patients with an aspiration to reduce
dependency on inpatient services both in Acute and Community Hospitals. This will
be achieved through a workforce and organisational development programme that
will drive up quality standards across all services, increase efficiency and support
community based integration and development of integrated teams of generic
workers who provide a more holistic approach to health and social care services.
High quality and engaging leadership and people management will be critical to
achieve the vision and objectives, and to creating an efficient and effective
organisation with a high performing culture. First and foremost this starts with the
DCHS Board.
9.1
DCHS Board
DCHS has developed a strong Trust Board with a blend of commercial and clinical
experience from a range of sectors.
Page | 176
The Board has thirteen members; six non-executive directors and seven directors,
five with voting rights, and a Trust secretary; the structure is outlined in Figure 9-1.
The Executive team structure aligns with the DCHS Constitution and fulfils Monitors
Code of Governance.
Figure 9-1 - Board Structure
Page | 177
Board members have been selected for their skills, knowledge and experience and
three members, the Chief Executive, Chief Nurse and Director of Finance have
previously worked in Foundation Trusts as Executive Directors.
The Non-Executive Directors provide support, challenge and scrutiny. They have
been selected to chair the sub-committees of the main board based on their
expertise and the challenge they can bring. Further detailed pen portraits of the Nonexecutive and Executive Directors are attached in Appendix H.
9.2
Workforce Profile
As at the 30th April 2014 our headcount was 3177fte (4098 staff) summarised in the
following staff groups:
Staff Group
FTE
Total Headcount
Allied Health Professionals
396.56
487
Health Care Scientists36
7.74
12
Medical & Dental
45.42
83
NHS Infrastructure Support37
1085.71
1445
Other Scientific, Therapeutic and Technical Staff
117.82
171
Registered Nursing, Midwifery and Health visiting
staff
899.87
1091
Support to clinical staff38
623.89
809
Grand Total
3177.00
4098
Table 8 - Headcount by Profession (as at April 2014)
Our workforce is 88% female and 63% work part time with 43% working 29 hours or
less per week; whilst having a part time workforce provide flexibility for our services it
does also present a challenge with regards to keeping all staff informed and ensuring
they receive all the development they need. The age profile of our workforce is that
52% are aged over 46 years whilst only 3% are aged less than 25 years old. 3% of
our workforce is black or from another ethnic minority group; 3% have declared a
disability and 46% of our staff have said that they have a particular religion or belief,
36
These are Phlebotomy staff
This includes Senior Management, Administration and Estates
38 This includes all Clinical support such as HCA’s Care Support workers and AHP support workforce
37
Page | 178
with 41% being Christian; and less than 1% has declared that they are lesbian, gay
or bisexual.
Across our workforce 45% of staff are registered clinicians and 20% are nonregistered clinical support staff, noting that some of this workforce will also be holding
Management and/or Corporate positions. We have 37% of our total workforce
providing infrastructure roles such as Administration, Hotel & Catering posts and that
which is required in the corporate offices, with 4% of our workforce come under the
coding of management.
In terms of Agenda for Change banding, 51% of our staff are in Bands 1 to 4 and
47% in Bands 5 to 9 (not including Medical and Dental.) In addition due to our high
staff retention rates, 67% our employees are at the top of their Agenda for Change
pay band and will therefore not be subject to any further incremental progression.
We have a range of clinical positions which are outlined in table X. These positions
are distributed across our service divisions with a small number of these staff in
corporate functions where a clinical qualification is required to undertake the role.
Staff Group Clinical
Pharmacy
Psychotherapy
Pharmacy Technicians
Other STT Staff
Phlebotomists
School Nurses
Education Staff
Clinical Psychology
Operating Theatre's / ODPs
GP, Community & PH (NHS employed)
Dentistry / Dental (NHS employed)
Other Nursing
Learning Disabilities (LD nurses)
Psychiatry (MH nurses)
Speech and Language Therapy
Dental
Chiropody / Podiatry
Occupational Therapy
Registered Health Visitors
Physiotherapy
Acute, Elderly and General (adult nurses)
Community Services (including district nurses)
Grand Total
Table 9 – Clinical Workforce by Profession (as at April 2014)
Page | 179
WTE
2.52
2.72
3.83
5.18
7.74
21.96
13.10
13.75
10.71
15.18
30.24
33.23
41.95
49.77
58.52
79.11
77.90
102.69
134.36
157.45
185.51
420.00
1467.40
Headcount
3
5
5
8
12
29
14
21
12
39
44
35
47
56
77
117
97
123
161
190
218
531
1844
9.3
Temporary staff
We utilise agency staff to meet short-term staffing needs across the Trust. To drive
improved quality and efficiency we have developed both a master vender agreement
with a leading agency that sources from a range of suppliers on our behalf at a
predetermined price and have our own internal bank along with an internal
‘responsive workforce’ team which is a peripatetic registered nursing workforce
employed on flexible annualised hours contracts which allow the team to be deployed
to areas of highest acuity to ensure optimum staffing numbers are maintained to
match patient needs and reduce agency spend. 370 of our own staff have a
permanent post and work on our internal bank.
9.4
Turnover
Our turnover historically has been just over 7% per annum. However, in 2012/13 this
increased due to releasing staff through a Mutually Agreed Resignation Scheme
(MARS) and then it fell again in 2013/14 fell to 9.74% as outlined in table X
Year
Apr-11
Apr-12
Apr-13
Apr-14
Leavers Headcount
362
337
565
424
Turnover
8.11%
7.12%
12.59%
9.74%
Table 10 - Turnover
9.5
Recruitment
On average we have 550 vacancies every year. During the last year we have
commenced pre-emptive recruitment through the “Caring never grows old campaign;”
where recruitment is actively managed through a talent pool approach since its
introduction 105 appointments have been made. In the 2013/14 we had 25 positions
that were “hard to fill” as they have been out to advert more than once or they have
been being actively recruited to for 3 or more months during the 12 month period.
Age Profile and Retirements
The retirement profile of our workforce is outlined in table x which highlights that 322
staff will reach the age of 65 by 2018/2019. We have an ageing workforce, mirroring
the demographics of the population we serve, with 52% of our staff currently in the
age range of 46 years and over. Many of these have special class pension status
and are able to consider retirement from the age 55 onwards. At present only 3% of
staff are aged 16-25 years; annually we are increasing our intake of Apprentices in
order to attract younger entrants into our organisation. We anticipate that the planned
changes to the NHS pension scheme and the on-going economic challenges will
have an impact on how many staff chooses to stay rather than retire.
Staff Group
2014
2015
Page | 180
2016
2017
2018
2019
Allied Health Professionals
Health Care Scientists
Medical & Dental
NHS Infrastructure Support
Other Scientific, Therapeutic
and Technical Staff
Registered Nursing,
Midwifery and Health visiting
staff
Support to clinical staff
Total
Total 65 & Over
1
1
1
10
0
0
1
19
0
0
3
22
1
0
2
28
3
0
0
24
5
0
0
38
1
0
0
1
1
0
3
7
24
80
6
6
32
112
3
5
33
145
5
10
47
192
15
12
55
247
17
15
75
322
Table 11 – Retirement Profile
9.6
Attendance
We have set ourselves an ambitious stretch target of 97% employee attendance.
Employee attendance is one of the key performance indicators measured at board
and with every people manager and employee though their personal appraisal.
Achieving this target remains a top priority in the Trust and has been the focus of
sustained attention during 2013/14.
Average Attendance %
Attendance %
2012
95.74%
2013
95.64%
2014
95.99%
Table 12 – Attendance Profile
9.7
Workforce Transformation Programme
Across our inpatient services we are further assuring our standards of care by having
published ratios of registered to unregistered staff derived from an evidence based
methodology that captures the appropriate ratios of staff for our care settings and the
acuity of our patients. Each ward will be supported by experienced Advanced Nurse
Practitioners and the input of General Practice and Consultants when required. We
will have a whole multi-disciplinary team therapeutic intervention approach to define
the overall staffing ratios required to meet patients’ needs going forward.
To achieve consistently the staffing levels we aspire to have will present a challenge
to attract, recruit and retain RGN’s, RMN’s, ANP’s, ENP’s, DN’s and Community staff
who have values and behaviours we expect. Building our brand and staff
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development offer will be essential to attracting the best staff to DCHS. Whether new
entrants or part of our current workforce we will support the development of a generic
workforce who is passionate about patient care. This will mean development
programmes that support core competency such as District Nurse training and
accelerated preceptorship programmes for newly qualified staff.
As part of our future workforce supply we will look to assure a talent pool of
unregistered clinical workforce by providing a professional development framework to
enable skills, competency and qualification development. As part of the overall
revision of services there will be ongoing investment into attracting and developing
Advanced Nurse Practitioners to support our changing medical model. There will be
skills mix changes and the development of some existing posts, increasing
productivity and the rationalisation of where services are provided in line with our
Estates strategy and in discussion with our local Commissioners.
Looking ahead as we progress with ongoing service improvements, an increased
focus on seven day services and changes to care models we will support our staff to
work differently and develop news skills. Recognising that eighty percent of the
workforce available to the NHS is already in post there is a nationally and locally a
large scale workforce development requirement. Some of the changes will result in a
reduction in some roles and posts, an increase in others, especially in some of the
corporate and support areas, clinical skill mix changes, continuation and expansion of
use of technology and agile working to increase productivity, new working patterns
and practices, a reduction in management layers where feasible and a change to the
environments that staff deliver services from.
Working in partnership with health and social care colleagues we will develop
Integrated Community Support Teams to provide holistic community based care to the
populations they serve. They will provide proactive case and disease management
and early interventions and rehabilitation to reduce and mitigate the need for acute
care. We aspire to develop generic workforce across health and social care at all
levels. There is an opportunity to combine the unregistered workforce to provide a
more efficient and effective support to patients and again this applies to the therapy
workforce. Across health and social care key workers will be integrated to provide
assessment and care. To achieve this we will need to expand the skills set of our
nursing staff so they can provide more holistic approach to assessment and care.
These teams will be led by an integrated management team without the need to
change employers.
In Children’s services there will be an ongoing focus on delivering our Health Visitor
target. To date we have been successful when recruiting Health Visitors and we are
well regarded as a place to come on placement and undertake training.
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Within Health Promotion services we know that many of the services will be subject to
a tender process. To win the tenders we will work with our staff to shape the delivery
models in order to meet future specifications. At a time of writing we are working on
the Integrated Lifestyles tender which will require a skills mix change and new delivery
model. Across the division there will be extensive reskilling and development and
rationalisation of where services are delivered from to maximise productivity.
Within Planned Care there is an ongoing review of the service model to take account
of changing requirements both within the demographics of the population and the
commissioning intentions and investment based on increased activity.
To support the shape and activity of the Trusts clinical services there will be ongoing
transformation of the corporate services considering the size and scope of
directorates, the changing estates strategy and the opportunity to increase efficiency
by pooling and sharing resources. Our Estates function will continue to work with
contracted out staff and bid for contracts to income generate.
We aspire to be an employer that supports youth employment by working with
schools, colleges, universities offering work experience, apprenticeships and graduate
placements.
There is a national focus on the quality, capability and compassion of NHS Leaders at
all levels with increased funding into development and ongoing discussion on how we
hold leaders to account for the cultures and climates they create. The expectations of
Trust boards for both Non-Executives and Executives has increased significantly with
additional responsibilities and expectations and for Executive Directors regarding the
Duty of Candour and Fit and Proper Persons requirement. We will continue to develop
our leaders and staff to have the skills and competencies they need for to be able to
fulfil the roles they currently hold as well as preparing for future roles.
To manage our headcount movements we will require investment and subtraction at
the same time and excellence in planning and delivery. We will look where possible to
reskill and skill mix and use national benchmarks as they are available. We will utilise
natural staff turnover to help manage the change and if finances and national
guidance allows the mutually agreed resignation scheme to support staff who wish to
voluntarily leave DCHS.
9.8
People Strategy
Quality People, The DCHS Way has three core themes Attract, Grow and Retain
and Engage underpinned by ten key focus areas and three strategic priorities as
displayed in Figure 9-2.
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Attract
Talent Attraction
Strategic Workforce Requirements
DCHS Integrated Business Plan
Talent Selection and Induction
Employee Development
Grow
and
Retain
Performing for Excellence
Maximising Health, Wellbeing and
Safety
Positive Employee Relations
Participation and Involvement
Engage
Rewarding and Recognising
Organisational Effectiveness and
Change Management
Excellence in Leadership and Management
Achieving Equality, Valuing Diversity
Excellence in Delivery
Figure 9-2 – People Strategy – Quality People, The DCHS Way
Attract; it is imperative that we can plan and predict our workforce requirements to
manage our workforce supply, development and deployment. When we recruit we
must to attract the very best staff whose have the values and behaviours to deliver
the very best patient experience and skills and competencies to deliver the very best
care. Nationally there is growing concern about the availability of qualified RGN,
RMN, RMLD Nurses, Advanced and Emergency Nurse Practitioners and Health
Visitors and where there is the supply the quality, values and behaviours are
variable. Therefore it is imperative that we have a strong employment brand and
offer that is attractive. We will select staff on what they can do and how they do it the values and behaviours they hold. Once we identify good applicants we will start
the on boarding process before they even start employment with us to enable early
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involvement and to develop a sense of belonging to DCHS which will then be
followed up with a robust induction process to ensure new appointees are well
positioned to be successful in their roles. On an ongoing basis we are reviewing our
employment offer to ensure our pay, terms and conditions are market competitive
and meet our business needs such as the changes we have made to our contract of
employment and the DCHS travel and mileage scheme which is market competitive
and supports our position to deliver care close to home.
Grow and Retain; we aim to maximise the potential of all our staff through their
development ensuring they have a clear job role, receive regular feedback, coaching
support and development programmes. We will be establishing a career
development pathway for unregistered staff to be able to develop their skills,
competencies and careers in DCHS and for registered staff to be able to maximise
their competencies and flexibility to work across teams and services and into
leadership should this be their career choice. Ensuring all clinical staff actively
participate in clinical supervision as part of their reflective practice and development.
An engaging and meaningful appraisal is essential to growing and retaining the very
best staff and we will continue develop our approach further. The health, wellbeing
and safety of our staff are paramount and we will support staff to maximise their
physical and psychological wellbeing and keep them safe whilst at work.
Engage, we know from international and national research the importance of an
engaged workforce to be able to deliver high quality services and to be a successful
organisation. We pride ourselves on the work we have done to date to engage with
staff but believe we still have a long way to go. We will work in partnership with our
staff and their representatives to develop our service models and respond to
commissioning and patient needs and look to influence both locally and nationally on
what high quality services and pathways of care look like. Through aligned service
improvement and organisational development interventions we will enable
organisational spread and adoption of best practice arising from continuous
improvement. To maximise organisational and individual performance we will focus
on organisational and individual job role design.
We have positive employee relations in the Trust and will develop this further through
joint development projects to enhance the DCHS employment brand. In DCHS we
recognise the importance of rewarding and recognising our staff but we know this
isn’t always consistently well done across the trust. We have our Staff Forum which
brings together Staff Governors, the Front Line Care Council and Partnership
Representatives which we nurture as an essential engagement process. To Attract,
Grow and Retain and Engage with our current and future staff we have identified
three core overarching strategic priorities, Excellence in Leadership and
Management, Equality, Valuing Diversity and Excellence in Service Delivery all we
believe are critical to achieving success.
To Attract, Grow and Retain and Engage staff is primarily undertaken by our
leaders and managers and therefore the quality of leadership across DCHS must be
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consistently excellent. We want to build on our success as an employer and provider
and ensure that all staff would recommend DCHS as a place to work and receive
treatment. We recognise that increasing the focus and profile of Equality, Valuing
Diversity is a requisite to achieving this. To achieve the delivery of this strategy
requires Excellence in Service Delivery from the People and Organisational
Effectiveness team in partnership with leaders and will require change in how we e
do things by raising standards and simplifying our policies and processes.
To summarise the key things we will be focusing over the next five years are outlined
in the table below:
ATTRACT
Talent
Planning



Talent
Attraction






Talent
Selection and
Induction




Operate a real time workforce planning process that is sensitive
to service and contextual changes to identify future workforce
under and over supply
Develop succession plans for all key roles across DCHS and
prepare staff for future roles
Work in close partnership with universities and training institutes
to influence the quality of workforce supply
Caring Never Grows Old recruitment brand that distinguishes
DCHS locally and nationally as a leading healthcare provider and
an employer of choice;
Targeted attraction campaigns to be spoilt for choice for all
vacancies
Exploit the use of all available medias to connect and attract
employees
Increase the diversity of our recruitment applications, focusing on
areas where want to enrich our staff profile
Position DCHS as youth employer across Derbyshire
Maximise the opportunity of local pay, terms and conditions
flexibilities to ensure DCHS is market competitive and can meet
our business needs
Have recruitment tools and techniques that ensures all
appointees have the right values, behaviours and competencies
Ensure our approach to recruitment attracts and supports a
diverse pools of applicants that apply and proceed to
appointment
Develop our leaders to advance their skills in recruitment and
selection
Commence on boarding with new appointees after acceptance of
an offer of employment and follow through with a robust induction
process that supports staff to understand DCHS and feel an early
sense of belonging.
GROW AND
RETAIN
Employee

Develop career pathways for clinical and non-clinical staff to
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Development
Performing for
Excellence
Maximising
Health,
Wellbeing and
Safety
enhance skills and professional development
Develop career pathways for clinical and non-clinical staff who
aspire to be leaders in DCHS
 Build a careers/skills escalator to support continuous
professional development of staff
 Provide models of development such as rotations to enhance job
enrichment and growth opportunities supported by preceptorship
and mentorship
 Provide IT access and training to all staff to increase productivity,
efficiency and engagement in the workplace
 All employees have a clear understanding of how role supports
the organisational and team goals
 Leaders and managers to set ambitious expectations of
performance and support each member of staff is supported to
achieve their very best
 Ensure policies and procedures enable staff to manage their own
performance and that of others; through effective performance
management
 Embed the across DCHS the e-appraisal system to enable staff
and leaders to capture their achievements, development
activities including clinical supervision and outputs from talent
management discussions.
 All staff to have access to the Your Health and Wellbeing
Matters programme to maximise their physical and mental
wellbeing
 A calendar of physical and psychological health campaigns to
support and raise focus on key health and wellbeing initiatives
such as the annual flu immunisation, national no smoking day
and to managing stress
 To provide a comprehensive occupational health and
psychological wellbeing offer.

mbed across the Trust the Stay Safe campaign, ensuring staff,
patients and visitor safety is of the highest priority to all staff and
leaders - all of the time.

ENGAGE
Positive
Employee
Relations





Work with other partners to horizon scan for best practice and
guidance and be up to date on national and local initiatives;
Work in partnership with trade unions, leaders and stakeholders
to ensure a well and productive workforce, maximise
collaborative working to minimise conflict;
Have in place effective and proven conflict resolution methods
Ensure all staff know how they can comfortably raise concerns
and use whistle blowing as a last result. Work with staff forum
and health champions to ensure staff have local support and a
range of ways to raise concerns
Transforming the relationships between frontline managers and
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E
Employee
Participation
and
Involvement





Rewarding
and
Recognising
our
Employees






Organisational 
Effectiveness

and Change
Management




employees to a culture of collaboration and problem solving
Maximise the opportunity and benefits of the DCHS Staff Forum
to support staff to raise concerns, challenge strategy and delivery
and hold the DCHS leadership team to account
Develop effective communication channels with staff to maximise
involvement and participation
Utilise the quarterly DCHS Pulse Check to identify early areas for
improvement, to spot trends, build on results and utilise the staff
friends and family test to report via the DCHS Big 9
To achieve 75% staff participation rate and be ranked as a top
performing trust as a place to work and receive treatment by our
staff in the national staff survey
Leaders engage their staff in the development and day to day
running of their services and service improvement
Achieve Sunday Times 100 ranking
Leaders know the preferences of each member of their team to
receive praise and recognition and provide timely and flexible
solutions to reward outstanding contribution
Talent is identified and realised through incentives to enable
individuals to maximise their potential
Excellent contribution of individuals, teams and organisational is
recognised and rewarded
Annual total rewards statement to provide staff with an insight
into their remuneration package
Develop a benefits scheme that supports staff to access local
and national discounts and tax relief opportunities
Aligned and focused service improvement and organisational
development interventions to key organisational priorities.
Enable organisational spread and adoption of best practice
arising from continuous improvement
To build an innovative culture pushing boundaries to ensure the
best quality of care is given to our patients. Working in
partnership with staff, patients, service users, governors, and
partner organisations, co creating the solutions to what needs to
change whilst delivering safe high quality care
Ensuring organisational structure and individual job role designs
maximise performance and engagement
DCHS Leaders support a culture of engagement, openness,
innovation and adaptability. Leaders support employees through
periods of transformational change and continuous improvement,
while creating a climate of commitment, high performance,
resilience and wellbeing.
To be open and transparent, giving people the facts behind the
need to change, whilst providing a road map of how the change
can be enacted.
STRATEGIC
PRIORITIES
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Excellence in
Leadership
and
Management




Achieving
Equality,
Valuing
Diversity






Excellence in
Service
Delivery





9.9
Provide targeted leadership development interventions aligned to
the talent management process. Development programmes split
into people management, clinical leadership and aspiring
leadership programmes
Build capacity and capability of our clinical leaders through a
robust development and assessment model
Build people management development programmes to further
align the skills and behaviours of the DCHS Way and enhance
people management capability
Aspiring leadership programmes to support the talent
management process
To equality impact service and organisational change for their
effect on all stakeholders to identify negative impact to remove or
reduce
Focus on initiatives that create a workforce that represents the
wider community
Focus on youth employment and development
Improve data collection about employees and service users to
provide equal access to services and opportunities and to tackle
unfairness or disadvantages
Further develop our network on equality champions and to
actively participate in national equality events
Progress our stonewall ranking making year on year
improvements
Employee relations cases are handled sensitively, timely and
consistently underpinned by a resourced investigation team
People management policies and processes are easy to find and
use for all leaders and staff to use
All leaders are confident and capable to use people management
practices
Electronic systems utilisation enables efficient processes and
transactional management
Staff are engaged and supported to actively embrace technology
and news ways of working
Ensuring delivery
The People and Organisational Effectiveness Directorate will champion the delivery
of the people and workforce transformation programme over the next five years and
will build leadership capacity and capability to enable successful delivery. The team
has the experience of managing organisational change and the reduction and
redeployment of staff.
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9.10 Monitoring progress
The Trust Board receives a monthly Quality People update covering both local and
national people metrics. DHCS has a Quality People Governance Committee to
provide strategic leadership, governance and assurance to the Trust Board regarding
the delivery of our people objectives. The People Governance Committee has four
sub committees; ‘Staff Partnership Forum’, ‘Workforce Planning and Development’,
‘Staff Health, Wellbeing and Safety’ and ‘Equalities Forum’ which will provide
assurance and delivery of the workforce and organisational transformation.
9.11 Risks and Mitigation
The risks associated with delivering our future plans have been considered and
mitigations developed to ensure successfully delivering as outlined below:
Top People and Culture Risks
Mitigation
Failure to recruit and retain the staff and
skills to deliver high quality services
Proactive recruitment and brand
programmes to build a DCHS
talent pool.
Cultural change could alienate some
staff thereby leading to disengagement
Ongoing communications, staff’
involvement and engagement
programmes. Focus on improving
people management.
Quality People, Service and
Business enables DCHS to keep
a close watch on key metrics.
Robust Quality Assurance
process is in place for all service
changes. Ongoing focus on
measuring patient experience.
Utilising the balance of
permanent and fixed term staff
allows for flexibility if DCHS
needs to reduce workforce
quickly.
For each severance scheme a
clearly defined criteria will be in
place to ensure reductions are
targeted to the right areas.
Leaders become distracted by the
implementation of new service
strategies and workforce changes and
lose focus on patient care/experience.
Income could reduce due to competitive
pressure and the reduction in workforce
numbers may need to be greater
MARS and severance schemes may
mean that experienced staff leave,
which could leave DCHS vulnerable
regarding loss of both knowledge and
experience and organisational memory.
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Maintaining employee engagement
through times of uncertainty and change
Decreased employee attendance
Decrease in training monies available
i.e. MPET etc.
Increase in employee relations,
disciplinary, grievances and ET claims
Adverse impact on patient care
Increasing the focus on
leaders/people managers’
capability and on-going employee
engagement events. Focus on
employee’s wellbeing and
alternative reward and
recognition programmes.
Robust attendance procedure
and focus on maximising
employee well-being and
preventive health measures
Maximising the internal capacity
and capability of clinical training
available. Ensure DCHS is
positioned to identify suitable
funding streams available
Robust organisational change
policy, developing our people
managers and early involvement
and reflecting lessons learnt.
Robust performance measures –
quality and people. Quality impact
assessment, safety walk rounds,
tracking skills mix and staff
surveys. Introduction of the
workforce assurance tool.
Key points of this section:

DCHS has an experienced and strong Board in place;

DCHS has workforce planning processes in place to ensure adequate control
of supply and demand over the five year period;

Engagement and involvement with staff is a priority for the organisation;

Leadership is an attribute expected from all levels of the organisation.
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10 Governance Arrangements
Purpose of this section:
 Describe the governance arrangements for DCHS.
 Describe how we engage with our stakeholders.
 Describe our approach to risk management.
 Describe the performance management framework.
10.1 Corporate governance and management
We have invested a significant amount of time in developing individual Board
members to enable them to fulfill their roles and in developing them collectively to
enable the Board to operate effectively. A formal programme of Board Development
has been delivered focusing on the requirements of an FT Board and on good
practice. This has been complemented by a programme of subject specific sessions
focusing on the requirements of the FT regime. All Board members have been
supported in their development through externally facilitated Coaching.
The Board has reviewed all formal documentation to ensure that it is able to prepare
for functioning as an FT. These documents have been formally adopted by the
Board. Through our Corporate Governance framework we have clearly defined
accountabilities outlined in our Standing Orders, Standing Financial Instructions and
Scheme of Delegation.
The issue of ‘Challenge’ at Board meetings by NEDs and Executive Directors has
been incorporated into the Board Development Programme including a 360 degree
appraisal of individual’s contributions. All challenges are recorded in the minutes.
The key methods of providing assurance to the Board are:
 The role of the Board Sub-Committees (See below)
 Board Assurance Framework
 CQC registration and Risk Assessment Framework
 Board Performance Framework
A training programme has been delivered to Committee members and authors of
Committee papers to ensure that committee expectations are met and that the role of
‘assurance’ is understood throughout the organization.
The Committees effectiveness is evaluated on a regular basis both in the
Committees meetings and as part of the regular Non-Executive Directors meetings.
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Formal Committee evaluation will be conducted on an annual basis.
At a Board development session in May 2011 it was agreed there would be three
main subcommittees of the Board based on the DCHS Way; Quality Service, Quality
Business and Quality People Committees.
There are three Board sub-committees:
 Quality Services Committee
 Quality People Committee
 Quality Business Committee
Each of the three sub-committees is chaired by a Non-Executive Director. The subcommittees take responsibility, on behalf of the Board, for the three aspects of the
DCHS Way. The Committees make decisions, shape and influence and provide
overall assurance to the Board with regard to Quality People, Quality Business and
Quality Services; each of these sub-committees has a number of groups reporting
into them.
In addition, there are two further sub-committees; the Charitable Funds Committee
and the Mental Health Act Committee which are also chaired by a Non-Executive
Directors. The Mental Health Act Committee reports through the Quality Service
Committee to the Board.
The Quality Service Committee shapes, influences and provides overall assurance in
relation to the quality of DCHS’ services. This incorporates the three elements of
quality governance i.e. – patient safety, the patient experience and the effectiveness
of care in relation to patient outcomes. This is achieved by working on the delivery of:









DCHS Quality Strategy
Compliance against regulatory requirements and external scrutiny:
Performance Framework
Controls and assurance
Effectiveness of care
Safety
Information Governance
Patient Experience
Mental Health Act Committee
The Quality People Committee oversees the development of the People and
Organisational Development Strategy providing assurance to the Board that DCHS
has the right staff, in the right place, doing the right things.
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This includes:
 Ensuring staff are recruited, trained, qualified and retained to do the roles
required
 Oversee the delivery of the People and Organisational Effectiveness Strategy
 Monitoring DCHS’ Quality People performance targets
 Ensuring that effective workforce plans and development are in place
 Ensuring effective workforce and development plans
 Ensuring DCHS has effective staff involvement and engagement
 Setting the aspiration of DCHS to become a great partner and teaching
organisation.
 Demonstrate compliance with relevant CQC Regulations and Outcomes, and
Employment Law requirements. Ensure compliance is maintained in relation
to the Health and Safety at Work Act.
The Quality People Committee has joint responsibility with the Quality Service
Committee to developing and assuring equality and diversity activity.
The Quality Business Committee shapes, influences and provides overall assurance
regarding the delivery of:
 Performance Framework
 Financial strategy and investment
 IM&T Strategy
 Business Development Framework
 Estates Strategy
 Integrated Business Plan (IBP)
 Business partnering arrangements
 Emergency Planning & Business Continuity
 Policy approval.
The following Committees are a mandatory requirement of the Trust:
 Audit and Assurance Committee
 Remuneration and Terms of Service Committee.
The Board and its sub-committees all have a reporting schedule for the year which
details the reports which will be presented at each meeting. Agenda items are also
requested before each meeting to allow for other business to be discussed in a timely
manner.
In February 2014, the Board approved the revised Corporate Governance Manual.
This document includes the scheme of delegation which details which items the
Board has delegated and to which committees and the Corporate Framework which
details the standard cover sheets and reporting templates for committees / groups to
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report to their parent committee. It has been agreed that this will be via a summary
report which will be sent to the parent committee after every meeting.
We will have a clearly documented relationship between Members, the Board of
Directors and the Council of Governors.
KPMG were commissioned as part of our Foundation Trust application to undertake
an assessment following the Board Governance Memorandum self-assessment
process.
The subsequent report identified many examples of good practice and did not identify
any significant risks from a Board governance perspective within the scope of work
undertaken and identified six recommendations at a low to medium priority.
These recommendations have been turned into an action plan which is being
monitored via the monthly CFT project board meetings.
10.2 Stakeholder interests
10.2.1 Membership
We have been clear throughout our pathway towards FT status that we view our
ability to recruit and grow an engaged membership is one of the main benefits of
authorisation. Our members and Governors are our most significant stakeholder and
we have identified significant resource to recruit and retain an engaged membership.
Our first Membership Strategy was drafted prior to beginning our member recruitment
to ensure we were clear on the benefits of membership and to enable us to recruit an
engaged membership with a clear ‘offer’. We adopted the public opt-in model to
ensure real engagement with being a member, with constituencies on a geographic
level. We allow staff to opt-out of the scheme as we expect staff to be
advocates/ambassadors of our Trust, with constituencies split across professional
groups. We have no specific patient constituencies.
Extensive public membership recruitment has taken place since July 2011 with a
wide range of activities. Highlights include a mailshot to 100k homes across our area,
recruitment stalls at more than 50 community events, face-to-face recruitment with
service users in our busiest outpatient facilities and a targeted mailshot to former
patients.
Page | 195
10.2.1.1
Membership Representation
By June 2014 we had a total of 17,323 members comprising of 12,293 public
members and 5,030 staff members.
As the population is ever-changing our membership database supplier Membership
Engagement Services (MES) states that an index between 80 and 120 is seen as
representative. We have endeavoured to achieve an in-house target of maintaining
indexes between 90 and 110.
The index for the Derbyshire constituencies as at beginning June 2014 is:
% of
Membership
Public
% of
Area
Base
Index
Amber Valley, Erewash &
South Derbyshire
3,279
33.80
334,077
32.36
104
Bolsover, Chesterfield &
North East Derbyshire
2,697
27.83
280,525
27.18
102
City of Derby
2,348
24.23
254,184
24.62
98
Derbyshire Dales & High
Peak
1,371
14.14
163,493
15.84
89
Rest of England
0
0.00
0
0.00
0
Out of Trust Area
0
0.00
0
0.00
0
9,695
100.00
1,032,279
100.00
Total
Please note we have removed the membership numbers for Rest of England and Out
of Trust area as these skew the indexes of the Derbyshire figures. This is because
we would be comparing a membership of approximately 2,000 for that constituency
against the population of the rest of England.
The Membership Strategy was updated in January 2014 to reflect a change in focus.
Having achieved our initial targets in recruiting a representative membership, we are
now putting increased focus and emphasis on our membership engagement.
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We still strive to form the largest practicable membership which reflects our local
communities both in terms of geography and demographics.
Our main objective now is to engage our membership in the work of DCHS, helping
to shape services and maintain a strong, complete Council of Governors. A key
message is focusing on members’ involvement in shaping local health services and
our commitment to members is to contact them at an early stage of any service
developments to enable them to actively inform the way forward.
10.2.1.2
What it means to be a member of DCHS
Public and staff members have a key role in the way DCHS is governed now and in
the future, and this is at the level they feel is appropriate. This means that they can:








Become involved in health service planning and consultation activity;
Stand for election as a Governor;
Vote in the election of the Council of Governors;
Become involved in our patient experience agenda;
Help promote healthy lifestyles;
Volunteer;
Learn more about local health services by attending dedicated member
events;
Get the same discounts as NHS staff with high street brands and local
businesses.
We aspire to:



Provide a range of opportunities for our members to get involved;
Increase membership each year in line with our membership targets;
Have the most effective Foundation Trust membership scheme in England
working with Membership Engagement Services.
10.2.1.3
Future recruitment activities
Future recruitment will focus on maintaining our current membership and building on
the areas/demographics where we do have a small under-representation, for
example the High Peak area and in Chinese and Pakistani ethnicities.
Future recruitment activities will also involve attending our health centres to talk to
service users about the benefits of our membership scheme, a targeted mail-out to
former patients and attending local community groups to highlight the services we
provide in the community.
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10.2.2 Shadow Council of Governors
In December 2012 we commenced Governor elections and our Shadow Council was
formed in March. The Council’s main duties are to:
 Hold the Non-Executive Directors to account for the performance of the Board
of Directors
 Represent the interests of the members as a whole and the interests of the
public
The Council comprises 17 Public Governors, 10 Staff Governors and 3 Partner
Governors. The following table shows the names of our Governors and their
constituencies:
Constituency Name
Public:
Amber Valley, Erewash & South
Derbyshire
Bolsover, Chesterfield & North East
Derbyshire
Governor Name
Ray Asher, Peter Ashworth, Bridget
Leech, Valerie Broom, Roz Coldicott,
Michael John Perry
Linda Barker, Lorraine Culpin, Barry Jex,
Sandra Moody, Maureen Strelley,
Derbyshire Dales & High Peak
Margaret Slater, Andrea Cooke, Brenda
Greaves, Paul Kirtley
City of Derby
Bernard James Thorpe
Rest of England
Diana Wood
Staff:
Nursing
Other Registered Professionals
Sally-Ann Coope, Ruth M. Francis,
Denise Sanderson
Sara Nash, Emma Meakin
Healthcare Support Staff
Tabitha Jane Crapper, Hazel Lowe
Medical & Dental
Amanda Smith
Facilities and Estates
Gavin Sykes
A&C & Managers
Adam Short
Partnerships:
Derbyshire County Council
Paul Jones
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North Derbyshire Clinical
Commissioning Group
Healthwatch
Jackie Pendleton
Karen Ritchie
The Council meets formally on a quarterly basis and this is supplemented by
Governor involvement in a range of other activities. Governor involvement is shaped
around four key areas:




Quality - Patient Facing
Quality - Environment
Membership
People Issues
The Governors were all asked for their interest and preferences regarding involvement
in these key areas. Council of Governor subgroups will be organised to update the
Council based around the four areas.
Further Governor involvement will be addressed through participation in key governance
committees and subgroups. We are considering which of the committees and subgroups
are most relevant to invite Governors to join.
Since the elections we have supported the Governors to identify and support their
development needs in understanding and holding to account a large NHS
organisation. We held a formal Induction programme for our Governors which has
been supported by an on-going development programme. We will continue to support
our Governors to ensure they are able to communicate with their constituency and to
recruit additional members. We utilise the skills and experience of our Governors
and ensure that they are provided with appropriate information to make informed
decisions.
We have worked with peers and affiliation organisations to test out our plans for
membership and the Council of Governors and this has helped to confirm our
strategic direction and shape our plans.
10.2.3 Other key stakeholder interests
We have developed positive relationships with our local Clinical Commissioning
Groups (CCGs) in Derbyshire and Leicestershire to both enter positive and proactive
contract negotiations and to seek clinical commissioner feedback on our service
development plans. Proactive discussions have helped CCGs to formulate and
refine their commissioning intentions. We will further enhance relationships through
the development of an ‘account management’ approach through service managers
and explore the potential to establish a GP liaison office (see section 9.2.3) .
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Our joint working with Derbyshire County Council (DCC) has been a significant
feature of our success through APO and NHS Trust status. We hold regular joint
Executive Team meetings with DCC and have worked in tandem in developing our
service strategies for the future to ensure they are aligned and provide integrated
solutions for local patients. Recent successes have included joint piloting of a clinical
navigation service for primary care which has resulted in a significant number of
patients avoiding hospital admission through joined up community and social care
triage. DCC have formally supported our plans for Foundation Trust status at each
key milestone.
In addition to this DCC currently commissions a number of our services, including
health promotion and learning disability services. The Health and Social Care Bill
extends this plurality of commissioners to include the Health & Wellbeing Board
along with NHS England, in addition to the local authority. These supplementary
commissioners will commission approximately £30 million of DCHS’ income, primarily
those services within the Health, Wellbeing & Inclusion division. Therefore DCHS
commenced engagement and collaboration with these parties at an early stage of the
service development process and this relationship is being further enhanced through
the joint approach to service planning.
We have proactively sought to develop partnerships with secondary care providers
within Derbyshire to ensure we can offer pathway solutions to future tender
opportunities. This has resulted in a formalised strategic partnership with Derby
Hospitals Foundation Trust with terms of reference approved by Board in September
2011. We have defined six initial workstreams where we expect partnership working
will be of benefit to both organisations.
We continue to develop our relationships with Derbyshire Healthcare NHS
Foundation Trust and Chesterfield Royal Hospital NHS Foundation Trust for similar
purposes and are confident of similar partnership agreements in the future.
We have historic good relations with local media and continue to see a good volume
of positive coverage relating to our services which is reported to Board monthly. The
communications team actively manages relations with key journalists to maintain
dialogue about future planning and takes a ‘customer service’ approach to ensuring
the needs of the local media are met in a timely manner.
10.2.4 Stakeholder engagement and relationship management
We recognise that understanding the needs of all stakeholders and responding in a
timely, professional and coordinated manner is critical to our business success. We
have developed our plans to support strategic stakeholder management &
engagement. This process includes regular formal review and feedback from our
stakeholders which we will use to improve performance.
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In particular, we will adopt an account management approach to primary care
engagement to further develop our well-established relationships with practices
through our historic provision of practice-based services. We have introduced
coordinated channels of performance communication with primary care and
introduced a system for account management in the first half of 2012/13. Dedicated
GP e-bulletins are circulated every two months to all GPs, CCGs and other relevant
stakeholders.
10.3 Risk Management
We have a Risk Management Strategy and Policy, both ratified by the Trust Board in
February 2014.
We are committed to a unified approach to risk management which is integrated with
safety systems and incident reporting. All incidents, risks, claims and complaints are
held within the DATIX Risk management system. The system provides a systematic
way of documenting, recording and monitoring the risks across DCHS (teams,
departments, divisions, directorates and the assurance framework (Strategic risks).
The risk assessment forms are the basis of the register. The Data held allows risks
to be analysed, themes and trends to be identified and reports provided.
The Board has the ultimate responsibility for risk management and the review and
approval of high risk treatment options. The risk management framework
encompasses:

A Risk Management Policy which describes our approach to risk management
including the processes, roles and responsibilities which underpin it. The
Chief Executive has overall responsibility for risk management processes.

A risk appetite statement within the Risk Management Policy which outlines
the level of overall risk the Trust is prepared to take to achieve its objectives
and provides staff with a guide as to their actions and abilities to manage risks.

A Risk Register held on the DATIX Risk Management system which stratifies
risk according to the Monitor classifications (Financial, Strategic, Operational /
Business, Clinical). This provides a library of current and historical risk
assessments and provides the Data to allow trend analysis and effective
reporting as well as analysis linked to incident reporting.

An approved Board Assurance Framework which is fully aligned to the Trust’s
strategic objectives. This records the organisation’s strategic risks, which are
all detailed on the Risk Register.

Risk management principles which are embedded within the business
planning processes requiring Divisions and Directorates to identify and record
risks linked to the Integrated Business Plan and the annual planning process.
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These principles are described in the policy under ‘Risk Management in
Practice’.

Risk Management principles which are embedded in our approach to the
project management of change whilst sufficiently balanced to allow the
development of innovative practice. These principles are described in the
policy under ‘Risk Management in Practice’.

The Quality Services Committee which provides the strategic leadership on
the management of risks. The Committee has delegated responsibility from
the Board to ensure that where risks are identified controls are in place to
support the achievement of DCHS business objectives, while minimising its
exposure to risk.

The Audit and Assurance Committee which reviews the Board Assurance
Framework at each meeting to ensure that strategic risks are being effectively
managed. The relevant sections of the Board Assurance Framework go to
their respective Quality Committee before being presented to the Audit and
Assurance Committee
The reporting of risk throughout DCHS is based on the aggregation of risk from the
front line to the Board This is known as the ‘Top X’ approach. ‘Top X’ allows staff at
all levels in the organisation to understand the risks they face at their level of the
organisation and where appropriate to manage that risk. Where this is not possible
the risk is escalated through the Divisional and Directorate structures to be managed
at the appropriate level.
We are committed to learning from incidents, Serious Case Reviews, Coroners
cases, disciplinary hearings and any claims. Systematic investigations take place
using agreed methodologies (outlined in the Investigation of Incidents, Claims and
complaints policy and Disciplinary policy). For serious incidents a Rapid Response
team is formed (see Incident Reporting Policy) who have a role in the dissemination
of learning. The Learning the Lessons Group reports to the Patient Experience
Group and provides the link through to the Quality Service Committee.
NHS Boards need to be able to demonstrate that they are aware of the clinical and
non-clinical risks facing their organisation. They need to be able to provide evidence
of the systematic identification of strategic objectives and the management of the
principle risks to achieving them. The assurance framework is the tool which is used
and which provides the structure to evidence the Annual Governance Statement
(AGS). The Board sets the strategic objectives and the key risks to achievement are
agreed by the Board.
The Annual Plan, Integrated Business Plan (IBP) and Cost Improvement Plan (CIP)
have been risk assessed by the Executive Team and appropriate officers as part of
the developmental processes. Consideration is given to all categories of risk as
demonstrated by the PESTLE analysis as well as those outlined in the Risk
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Management Strategy. Monitoring of the risks to quality posed by the IBP and CIP
will be undertaken on quarterly basis using the Quality Impact Assessment tool with
exception reporting of any risks identified through Early Warning Indicators.
10.4 Performance management reporting framework
In preparation for foundation Trust status, the Trust has introduced a new
Performance Framework which defines a way forward for improving the performance
of the organisation through the areas outlined within the ‘DCHS Way’ - quality
service, quality people and quality business. It supports the concept of service line
management, driving down responsibility to service lines at the point of service
delivery. This is underpinned by a comprehensive reporting structure that delivers
information to support the management of service lines.
It provides a strategic framework to enable overall coordination of all performance
management activities across the Trust and ensure alignment with the Trust’s
business strategies and strategic objectives and underpins the Trust’s Assurance
Framework.
The Board and the Quality Business Committee receives the performance report at
every meeting. Performance review meetings with divisions are undertaken monthly,
with a formal quarterly review attended by the Executive team. These reviews cover
all elements of the DCHS Way.
The over-arching Performance report has been modified in preparation for foundation
Trust status and the report now covers the following: An exception narrative which draws Board members attention to key issues
 A RAG-rated balanced scorecard and a glossary of terms to clarify any of the
indicators being reported against. In addition the “Healthcare Acquired
Infection” CQUIN indicators and referral to treatment (RTT) indicators have
been incorporated into the report.
The performance targets are reviewed annually and on an ad-hoc basis where
required. As well as wider regulatory drivers, Board Development sessions are often
a source of new measures, and an opportunity to assess whether the existing ones
are fit-for-purpose.
The measures are built around three specific areas: DCHS Way – Indicators that support the delivery of the organisations strategic
aims and that are embedded across the Trust via the appraisal process.
 National Targets – These are as per the technical guidance accompanying the
2012-13 Operating Framework and Schedule 5 of the new Multi-lateral
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Community Services contract. These are a combination of targets set by the
Department of Health and Commissioners.
 Internal Targets – These are targets that support the delivery of the Trusts
objectives and are of specific interest to the Board.
Much of the data – and all Clinical measures – are subject to Data Quality (DQ)
procedures, and it is planned that all measures will be under a DQ kitemark shortly.
In addition to reporting the year to date performance, where appropriate a forecast
year end position is reported.
10.5 Financial controls and reporting
The Trust has Standing Financial Instructions in place. These were reviewed by the
Audit and Assurance Committee and approved by the Board in February 2014.
Below the Standing Financial Instructions are a number of procedure notes for each
of the key financial systems. The key financial systems are audited on a regular basis
with assurance opinions reported through to the Audit and Assurance Committee.
A scheme of delegation is in place which sets out the authority levels for expenditure.
The Trust has an Annual Governance Statement (AGS) in place.
10.6 Audit Arrangements
10.6.1 Audit and Assurance Committee
The Trust has a formally constituted Audit Committee, with terms of reference
approved by the Board. The Committee comprises 3 non-executive directors and
has the role of providing the Board with assurance over its systems, processes and
functions to ensure sound internal control.
The Committee comprises non-executives with significant experience in a mixture of
NHS and Finance matters. It has an unfettered right to investigate any area of the
Trust’s operations, including the commissioning of legal or other professional advice
and the ability to restrict attendance to the Committee meetings / meet in private.
The Committee was established on 1st April 2011 when the organisation became an
NHS Trust. The Terms of Reference reflect the best practice code for Audit
Committee as described in the 2011 Audit Committee Handbook. The Committee
has undertaken reviews against best practice guidance including the Audit
Committee Handbook, Figures You Can Trust, and Taking It On Trust, and has
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action plans in place to ensure the recommendations are implemented to improve
governance within the organisation.
10.6.2 Internal Audit
Internal Audit services are provided by 360 Assurance (formally East Midlands
Internal Audit Service).
The following draft opinion was provided by the Head of Internal Audit for the period
1st April 2013 to 31st March 2014:
“Significant assurance can be provided that there is a generally sound system of
internal control, designed to meet the organisation’s objectives, and that controls are
generally being applied consistently”.
The Head of Internal Audit opinion is additional external assurance which supports
the Accountable Officer in signing off the Annual Governance Statement (AGS) on
behalf of the Board.
The internal audit plan for 2013/14 was for 400 days. It is derived from a risk based
approach to cover the following areas:








Financial Management
IM&T
Performance / Data Quality
Clinical Quality
People Management
Governance, Risk and Legality
Contingency
Management, Development, Advice and Follow Up
70 days
20 days
60 days
70 days
45 days
20 days
40 days
55 days
Outcomes from the reviews are reported to the Audit and Assurance Committee. The
Audit and Assurance Committee also receives updates on progress in implementing
agreed recommendations.
These internal audit reports provide the Board with assurance across all areas of the
Board Assurance Framework.
10.6.3 External Audit
KPMG was appointed as the Trust’s new external auditor from October 2012 when
they took on Audit Commission work in the East Midlands.
The Audit Commission issued an unqualified opinion on the Trust’s latest set of
accounts in June 2014, and issued an unqualified value for money opinion.
10.6.4 Counter Fraud
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Counter Fraud services are provided by 360 Assurance Counter Fraud services and
the number of days in the current year’s plan is 95.
Fraud prevention is a feature of many DCHS policies, including losses, general code
of conduct and others, and is the specific concern of a Counter Fraud policy and one
for Whistle Blowing.
The Audit and Assurance Committee receives a quarterly update from the Local
Counter Fraud Specialist on progress against the plan, and updates as to current live
cases and progress.
10.7 Provider License:
To prepare for operating under the Provider License regime, the Trust has introduced
a quarterly process for undertaking a shadow self-certification against the
requirements. This process has been introduced as developmental for the Board. It
allows the Board to understand the detail required enabling a self-certification to be
made, and it allows the Board to be proactive in addressing any areas where there
may be concerns around compliance.
The Board is very aware of the concerns Monitor has raised around the quality of
self-certifications made by foundation Trust Boards. The Audit and Assurance
Committee has therefore undertaken a self-assessment against the Audit
Commission report “Taking it on Trust” and against recommendations made by
Monitor following a review of self-certifications in Foundation Trusts. An action plan
has been implemented.
Compliance against the Continuity of Service financial rating is monitored through the
monthly finance report. This report is presented to the Quality Business Committee
and then the full Board.
Key points of this section:

DCHS has a robust approach to governance.

DCHS engages its key stakeholders

DCHS has a proactive approach to risk management.

DCHS has reviewed and strengthen its performance framework and has a
systematic approach to reviewing performance across the organisation.
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11 Appendix A - Abbreviations
AGS - Annual Governance Statement
ANP – Advanced Nurse Practitioner
APO – Autonomous Provider Organisation
AQP – Any Qualified Provider
BAF – Board Assurance Framework
BCF – Better Care Fund
BME – Black and Minority Ethnic
C&SH – Contraception & Sexual Health
CCG – Clinical Commissioning Group
CFT – Community Foundation Trust
CIP – Cost Improvement Plan
CNO – Chief Nursing Officer
COS – Continuity of Service
CQC – Care Quality Commission
CQUIN – Commissioning for Quality and Innovation
CRHFT – Chesterfield Royal Hospital Foundation Trust
DATIX – DCHS’s risk management system
DCC – Derbyshire County Council
DCHS – Derbyshire Community Health Services NHS Trust
DHFT – Derby Hospitals Foundation Trust
DTC Diagnostic & Treatment Centre
EBITDA – Earnings Before Interest, Tax, Depreciation and Amortisation
EFL – External Financing Limit
ESR – Electronic Staff Record
FFT – Friends and Family Test
FRR – Financial Risk Rating
FT - Foundation Trust
FTE – Full/Whole Time Equivalents
GP – General Practitioner
HCAI – Healthcare Acquired Infection
HFMA – Healthcare Financial Management Association
HWBI – Health, Wellbeing and Inclusion
IBP – Integrated Business Plan
ICATS – Integrated Clinical Assessment and Treatment Service
ILP – Improvement Leaders programme
IM&T – Information Management and Technology
KPI – Key Performance Indicators
LD – Learning Disabilities
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LTFM – Long Term Financial Model
MARS – Mutually Agreed resignation Scheme
MAT – Multi Agency Team
MDT – Multi-Disciplinary Team
MIU = Minor Injuries Unit
MSK – Musculo-skeletal Service
NICE – National Institute for Health and Clinical Excellence
NHS – National Health Service
ONS – Office for National Statistic
OPMH – Older People Mental Health
PCT – Primary Care Trust
PDC – Public Dividend Capital
PESTLE - Political, Economic, Social, Technological, Legal & Environmental
PMO – Programme Management Office
QIA – Quality Impact Assessment
QIPP – Quality Innovation, Productivity and Prevention
QRP – Quality Risk Profile
RDHFT – Royal Derby Hospital Foundation Trust
RTT – Referral to Treatment (usually a time)
S&LT – Speech & Language Therapy
SBS – Shared Business Services
SIC – Statement of Internal Control
SLM – Service Line Management
SLR – Service Line Reporting
SPA – Single Point of Access
SWOT – Strengths, Weaknesses, Opportunities and Threats
TDA – Trust Development Authority
TPP – Name of the company supplying the SystmOne patient administration system
VOIP – Voice Over Internet Protocol
WTE – Whole/Full Time Equivalents
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