Appendix 5A

NHS BUDGET SCRUTINY

KEY QUESTIONS

Group 1 – STRATEGY AND CAPITAL INVESTMENT

1a What is the strategy behind the budget proposals?

1bWhat are the main policy issues over the medium term?

1cHow are the budget proposals consistent with Commissioning Priorities?

1dHow are the budget proposals consistent with the Trust’s priorities?

1eWhat are the capital investment priorities for the Trust? Is there a backlog of maintenance and if so, how is this being managed?

1fWhat is the scope for maximising external funding for capital investment (e.g. Government grants, developer and other third party contributions, etc)?

1gWhat is the scope for rationalising property (e.g. by sharing with others, by service re-design, by better utilisation, etc) and so generating capital receipts?

1hHow has the corporate priority for low carbon/sustainability influenced the capital programme?

1iIs the programme achievable on budget and time? What are the risks of cost overrun or slippage?

East and North Hertfordshire NHS Trust (ENHT)

1aThe overall strategy for the health system will be to operate with minimal levels of real terms growth over the period and to continue to maintain current performance standards.

The Trust’s financial strategy in its 5 year Long Term Financial Model is consistent with the current DH Operating Framework and Monitor’s guidance and assumptions.

Besides national policy and the overriding economic conditions, the key aspect of local financial planning for the Trust is the implementation of its acute consolidation strategy ‘Our Changing Hospitals’.

1bSome of the main policy issues and drivers over the medium term are:

- Improving quality and, in particular, outcomes for patients without an increase in real levels of funding;

- Reducing acute capacity in overall terms through a combination of measures including prevention, improved pathways of care, more local settings etc;

- Putting patients first and thereby ensuring their care, their safety and their overall satisfaction is at the centre of ‘what we do’.

1cThe Trust’s financial strategy is entirely consistent with the Hertfordshire QIPP Programme and the commissioning intentions of our lead commissioner, NHS Hertfordshire. Chief Executives are joint signatories of the QIPP plan and the PCT are formally supportive of the acute consolidation business cases as well as the financial plans supporting the Trust’s FT application.

1dThe budget plan for 2012/13 is aligned with the Trust’s strategic objectives and its overall vision. Formal sign off by the Board ensures this consistency of approach and synergy.

1eThe Trust categorises backlog maintenance according to risk and prioritises investment within the capital programme accordingly.

The Trust’s backlog maintenance figure is broken down in to four categories (high, significant, moderate and low). The Trust total figure for backlog maintenance is £39.322m. This figure reduces to £19.624m by 2014 following consolidation.

There will remain a significant amount of further refurbishment required to the balance of the estate, as indicated by the estimate of backlog maintenance at the end of the programme. The Trust is committed to using its improved financial position consolidation to fund a refurbishment programme to bring the balance of the estate up to Consolidation B or better.

1fThe Trust’s Our Changing Hospitals Programme involves achieving the consolidation of acute services at the ListerHospital site. The acute consolidation delivers a £14m land sale receipt that forms a key component of the Trust’s capital investment strategy at the ListerHospital site.

The consolidation programme relies heavily on the implementation of new models of care to deliver improved outcomes for the local community.

1gAs above.

1hThe Trust has a significant programme of capital developments underway and planned on site at the ListerHospital. In terms of major new developments on site the Trust has worked to ensure that all new build developments and refurbishment works comply with Building Research Establishment Environmental Assessment Model (BREEAM) healthcare requirements.

BREEAM sets the standard for best practice in sustainable design and has become the de facto measure used to describe a building's environmental performance.

The Trust anticipates achievement of ‘Excellent’ ratings for new build developments and ‘Very Good’ for refurbishments.

In addition to the new developments on site at ListerHospital to achieve acute services consolidation the Trust continues to consider a number of invest to save schemes to improve sustainability and reduce carbon emissions. Schemes include the introduction of sub metering to allow effective monitoring of energy consumption, the fitting of restriction to high flow water outlets and the installation of sensor taps across the Trust.

1iAs above.

East of England Ambulance Trust

1aThe overall strategy is to manage increasing patient demand, provide patients with a better quality of care whilst delivering this more efficiently and effectively.

1bThe main policy issues include how ambulance services will be commissioned in the future, managing a cost improvement programme (CIP) which requires the Trust to reduce operating costs by £60m over five years (2012/13 is year two) and to manage demand driven by an increasing population (with a rise in the number of elderly people and those with long term conditions)

1cCommissioning priorities are to treat more patients within the community and reduce admissions to secondary care and to reduce the cost of providing ambulance services whilst retaining the quality of service provided. This aligns directly with the Trust strategy of providing a more tailored response to patients based on the right care, in the right place at the right time.

1dThe redesign of the Trust’s service model, through the introduction of an Integrated Service Model, will help ensure the cost improvement programme target is met. Through service redesign the Trust will manage the demand for emergency services more effectively while using fewer resources, thus creating additional capacity to help cope with increases in demand. This redesign will also help to reduce the overall unit cost of responses and provide a better and more tailored service for patients.

1eCapital investment is planned at c. £11m in 2012/2013 which includes investment financed by Department of Health for the new Hazardous Area Response Team buildings, Information Technology investment and investment in our Estate from a backlog maintenance, infection control and carbon reduction perspective. Backlog maintenance is part of a planned programme within the Trust and a new six facet survey has been commissioned to update the plan.

1fThe Trust has secured income from the Department of Health to support a new build development for the second Hazardous Area Response Team. All other capital expenditure is self financed.

1gThere is some scope for rationalisation of estate. The move to a new Headquarters 18 months ago enabled the Trust to rationalise some if its legacy estate. The Trust is keen to take advantage of partnership opportunities with NHS, police, fire and other organisations for sharing estates and facilities. The Trust has considerable experience of sharing facilities, particularly with fire and police in Hertfordshire and Norfolk respectively. The Trust continues to develop relationships with partner agencies and such discussions are ongoing. The scope for savings from such initiatives is relatively small, however, as most sites are small.

1hAll business cases address carbon reduction requirements. The Trust has an ambitious programme of carbon reduction in place and has become one of only three ambulance services in the country to join a scheme run by the Carbon Trust that will aim to cut its carbon emissions by nearly a third. If the Trust hits this target it will also save around £6m.

Capital expenditure of £0.4m has been identified to support this programme.

1iThe programme is achievable both within the budget and on time. The risks to the programme are around potential slippage as this is an extensive programme of work. This risk is mitigated by having a significant amount of business cases in place before the start of the financial year.

NHS Hertfordshire (PCT)

1aThe budget proposals are based on the PCT’s refreshed Strategic Plan (January 2010), and the second year of the QIPP plan (published September 2011). The shadow CCGs (East and North Herts CCG and Herts Valleys CCG) have also developed financial plans based on the same planning assumptions and strategy.

All of these have been collated into the Integrated Plan that is currently being finalised. This has had input from the CCGs and all Providers

1bThe priorities set out in the PCT’s integrated plans, and supported by the shadow CCGs are:

Health inequalities – to reverse the variation in health outcomes and reduce health inequalities;

Birth (caesarean birth rates) – to review pathways and consider future impact of recent NICE guidance on service quality and capacity;

Children – reduction in childhood obesity rates;

Stopping smoking – to reduce major illness by reducing smoking;

Patient safety and safe care – to maintain and improve patient safety;

Stroke – to continue effort to maintain the vital sign target of more than 80% of patients spending 90% of their time on a stroke unit;

End of life – to pilot a number of schemes to determine how best to use resources to ensure that any patient within the last 12 months of life can easily access health and social care help and support;

Access to GP services – to work closely with practices where access needs to be improved and with CCG locality groups to address underlying issues;

Cancer services – To work with the Mount Vernon Cancer Network to progress a focussed programme of work directed towards improving survival rates;

Better integration of care – To continue developing the intermediate care strategy;

Long term conditions – to develop care pathways that integrate services across primary and secondary care settings;

Care Homes – to work with the Hertfordshire care home providers on a number of initiatives to improve care to patients, reduce admissions to hospital and support our end of life care work.

The PCT is also working to deliver the following national and SHA priorities, which reflects some of the above:

NHS Operating Framework / NHS OUTCOMES FRAMEWORK / SHA Ambitions:
  • Dementia and care of older people
  • Carers
  • Military and Veterans Health
  • Health visitors and family nurse partnerships
/
  • Preventing people from dying prematurely
  • Enhancing quality of life for people with long-term conditions
  • Helping people to recover from episodes of ill health or following injury
  • Ensuring that people have a positive experience of care; and
  • Treating and caring for people in a safe environment; and protecting them from avoidable harm
/
  • Eliminate pressure ulcers
  • “Every patient contact counts”
  • Quality/Safety in primary care
  • Strengthened NHS/LG partnerships
  • Improve patient experience

1cThe budget proposals reflect the work streams set out in the QIPP programme. These work streams are inter-linked and interdependent. This is described in the following diagrammatic way. The CCGs are clear that in combination all programmes support the delivery of the QIPP in terms of quality, activity and financial outcomes but that it is the system and total picture that we need to focus on, not just the specific projects.

1dThe budget proposals are consistent with the Trusts’ long term financial models which are developed in support of the Trusts’ NHS Foundation Trust pipeline plans.

1eNot relevant to the PCT where there is very little capital investment

1fN/A

1gN/A

1hThe PCT is ensuring that the development of the New QEII and the LGH. The Tenants’ Requirements set out clearly the need for the design to meet, if not improve on all current design guidance with regards to sustainability. The New QEII addresses sustainability in a number of areas:

•Building Research Establishment Environmental Assessment Method (BREEAM) Healthcare quality assessment is a holistic assessment for the project as a whole, and embraces all aspects of energy conservation associated with the design and construction of a building.

•Green roofs

•Use of Photovoltaic and solar panels

•The use of grey water
The NHS requires all construction projects to undertake BREEAM and it is based upon a weighted score for various credits contained within 9 assessment categories, as detailed below, plus an “innovation” category.

• Management

• Health and Wellbeing

• Energy

• Transport

• Water

• Materials

• Waste

• Land Use and Ecology

• Pollution

Energy efficiency will meet Building Regulation and CIBSE guidelines and exceed expectations as identified in ‘Good Practice’ delivered energy performance benchmarks and CO2 emissions benchmarks in HTM-07-02 EnCO2de.

1iThe New QEII stage 1 business case set out an affordability cap. The current work to develop the stage 2 business case ensures that the scheme is delivered within this envelope. The LIFT partner works closely with the PCT to agree the timeframe and delivery of the scheme.

The scheme is on schedule to produce the Stage 2 business case in May 2012.

Hertfordshire Partnership Foundation Trust (HPFT)

1a The Trust is committed to providing excellent health and social care for both people with mental ill health and those with a learning disability. We aim to provide services which make a positive difference to the lives of service users and their carers, underpinned by the principles of choice and independence, delivering high quality, safety and ensuring sustainability. The partnership arrangements with the local authority provide an excellent opportunity to develop a recovery orientated approach based on holistic assessment of both health and social care needs.

1bThe White Paper Equity and Excellence: Liberating the NHS sets out the Government’s strategy for the NHS. The intention is to create an NHS which is much more responsive to patients, and achieves better outcomes, with increased autonomy and clear accountability at every level. The key themes are:

  • Improving public health, tackling health inequalities and reforming social care
  • Putting patients and the public and patients first, increasing choice and control
  • Improving healthcare outcomes, implementing quality standards
  • Increasing autonomy, accountability and democratic legitimacy
  • Cutting bureaucracy and improving efficiency

The 2010/2011 NHS Operating Framework focussed on and reaffirmed five national priorities, or ‘vital signs’:

  • Improving cleanliness and reducing infection
  • Improving access and reducing waiting
  • Maintaining well-being, improving health and reducing health inequality
  • Improving patient experience, staff satisfaction and engagement
  • Being prepared for emergencies

The Operating Framework for 2012/13 builds on these, containing a dedicated chapter on quality, with the specific aim of ‘Improving services and patient experiences during 2012/13’. The areas that require focus are:

  • Dementia and Care for Older People
  • Support for Carers
  • Military and Veterans’ Health
  • Health Visitors and Family Partnerships

These dovetail with the devolved responsibilities of the Trust in delivering integrated health and social care reflecting the ‘Putting People First’ agenda including:

  • Personalisation of Care
  • Services to lengthen independence – prevention and early intervention
  • Safeguarding adults and children
  • Improving access to services
  • Bottom of Form

HPFT has drawn these together with previous proposals around ‘Investing in Your Mental Health’ in Hertfordshire to develop a significant service transformation programme entitled ‘Leading by Design’.

1cThe Strategy for Mental Health sets out:

Services and support should be available as close as possible to where you live. How people integrate into their communities is important. Services locally provided will strengthen links and raise local profiles and visibility. A move towards a wider range of providers of services in the community rather than through statutory organisations will provide a better fit. Enhancing lives and promoting engagement is important and what is fundamental is how people spend their days. These enable access, promote socialisation and reduce the effects of stigma and discrimination.

We are responding to this through:

  • working with partner agencies and the voluntary sector for the provision and delivery of day opportunities, developing a greater choice and variety of services available, they will be closer to where service users live, they will be of a higher quality and better targeted to service users needs, they will be more efficient, assisting us to transform services and meet the financial savings we are required to deliver in adult social care.
  • our hubs and spokes approach to estate rationalisation, ensuring more services continue to be provided within local communities and our investment in mobile working to support staff to deliver services closer to home in the most effective and efficient way

Self help and help from family carers and others who have experienced mental health problems We have invested in our peer support scheme, enabling those with lived experience to work with service users towards recovery. Increased access to peer support and increased user lead social support is seen as pivotal in helping service users towards recovery and maintaining independence and well being. Peer support will ensure that people who have had significant experience of mental distress can work alongside others with similar difficulties in order to assist recovery. Furthermore peer support is a way for people to come together with shared experiences and the intention of changing unhelpful patterns and moving beyond their perceived limitations. The culture of peer support provides a sense of community, and often begins with informal and naturally occurring support which is also normally the bedrock of Service User run groups. In essence Service Users use their own knowledge and expertise to help both themselves and others. This help is rooted firmly in personal experience, which is acknowledged as the most powerful and effective way of learning and averting crises.

There will be an advice and access service which will quickly route you to the most appropriate help Our Single Point of Access Service commences from April 2012.There will be a single point of access operating from a single site for all new referrals to HPFT specialist mental health for children and adults and learning disability services. This access point will receive referrals and identify those who need specialist help and assign them to a recovery care pathway according to their needs.