Page 1 of 16
Key contacts at Trust (name, telephone number, email address)Name / Title / Telephone / Email
Executive Lead:
Finance:
Workforce: / Lesley Stephen
Barbara Byrne
Linda Dyson / 020 8354 8153
020 8354 8250
020 8354 8728 /
SECTION 1: STRATEGIC OVERVIEW
Provider Landscape and timescale to end state as a result of implementation of Healthcare for London. Where do you expect to be at the end of and 2010/11 and 2011/12.
The Trust has undertaken a series of planning events at Board and clinical leadership forums and with its partner and commissioning organisations to determine how best to drive quality improvements through revised clinical pathways and thereby achieve improved productivity.
The initiatives which should achieve these changes include:
- Redefining the borough based catchments of inpatient services, initially within Trust boundaries, but moving toward service provision where appropriate in conjunction with neighbouring Mental Health Trusts (“MHTs”);
- Ending borough based inpatient services for Older People’s Services to facilitate separate management of organic and functional illness;
- Moving toward needs based services rather than age based services and thus integrate adult & OPS CMHTs;
- Refocusing the remit of CMHTs to facilitate improved patient pathways into and out of more specialist care, including inpatient care;
- Continuing to develop community forensic services, to facilitate discharge and reduce length of stay;
- Shifting care from medium to low secure settings, in response to commissioning intentions and to improve rehabilitation services, thus reducing lengths of stay; and
- Reducing the consultant to patient ratio in High Secure Services in agreement with Commissioners.
To facilitate all of the above, the Trust envisages improved efficiencies and savings from the following areas:
- Decommissioning of services not fully funded
- Emphasis on prevention and working more effectively with primary care
- Removing duplication and improving integration
- Skill mix reviews
- Reduction in administration support by realising the benefits of Rio v5 implementation
- Estate rationalisation, both in inpatient and community facilities.
SECTION 2: PERFORMANCE
Please describe your interaction with your Sector Acute Commissioning Unit
Our local services are commissioned by Ealing, Hammersmith and Fulham and Hounslow PCTs. Ealing PCT co-ordinate these a collaborative approach to the commissioning of local services. There is not formal lead commissioning arrangement.
Forensic services are commissioned through the National Oversight Group (Broadmoor) and the North West London Commissioning Consortium (low and medium secure services).
Commissioning relationships with each of these PCTs/Consortia have been positive during 2009/10 and discussions re 2010/11 are progressing well.
Are all operational targets forecast to be met? If not, which ones are unlikely to be met, is there an action plan in place and what is the timescale for achievement?
The Trust is forecasting that it will meet the majority of operational targets, as defined by the CQC Periodic Review and the DH Performance Framework through 2010/11.
However, it is predicted that in the DH performance assessment at quarter 1 2010/11 as well as results of the 2009/10 CQC Periodic Review, the Trust will be under-performing against 2 targets; data completeness of the Mental Health Minimum Data Set and Delayed Transfers of Care (DToCs).
The Trust underachieved these indicators in the CQC Annual Health Check for 2008/9:
- The DToC data was extracted from Q1 sitreps and the threshold for achieved was only just missed by the Trust (Achieved threshold 7.5%, Trust performance 8%, underachieved threshold 7.5% - 15%).
- The MHMDS completeness target is a composite of 8 data quality indicator fields. In all but one of these fields the Trust achieved over 90% recording, in three fields 100%. The field which reduced the Trust’s overall compliance was recording marital status, which the Trust had not previously prioritised for data recording.
There has been improvement through the year on data completeness of the MHMDS, and we are forecast to reach the target by Q2 2010. DToCs already have a series of action plans in place through the CQC action plan, and steady improvement has been achieved through the year.
Reducing the number of DToCs is also an expected outcome of developments in the 2009/10 and 2010/11 Business Plans to improve care pathways in local services, which are in line with initiatives set by Healthcare for London; developments include large-scale inpatient and community service reconfiguration in Hammersmith and Fulham SDU and changing the function of community teams in Ealing SDU.We forecast that we will meet the target by Q3 2010/11.
The Trust is also predicting a potential underachievement against 2 of the Operational Standards indicators within the DH performance framework: the proportion of service users on CPA in employment and proportion of service users on CPA in settled accommodation. Predicted underachievement of these targets is as a result of data recording which is currently low for both these indicators. Recording of both indicators has only begun in 2009/10 Q3 as part of a phased development agreed with the PCT through CQUIN targets.
SECTION 3 FINANCIAL PLANNING
Commentary on clinical revenue
The above figures are for NHS clinical revenue as shown in the NHS Clinical Reconciliation section of the Financial Plan
Please explain the significant changes in clinical revenue including:
Tariff/price changes
Plan assumes zero increase in tariff 2010/11 and reduction of 0.5% in 2011/12.
Plan assumes increase in CQUIN funding from 0.5% 09/10 to 1.5% 10/11 (i.e. an extra 1% in 2010/11).
CQUIN funding has been treated as non recurrent and therefore not in the “opening baseline” figures.
Expenditure equal to the income is assumed but this could be managed flexibly if the full CQUIN funding was not achieved.
Market Forces Factor n/a
Investments
a) Increases planned 2010/11 include HFPCT assertive outreach tender £418k; full year effect of IAPT HFPCT £354k; restoration of £800k funding for DSPD (High Secure national contract); increased income for Gender specialist service from cost per case £110k; full year effect of Integrated Action Plan at Broadmoor High Secure contract £309k.
Divestments
b) Loss of income includes Bedfordshire forensic contract £874k; Camlet women’s forensic contract £472k (part year); LB Ealing loss of £304k mental health grant funding.
c) The plan assumes a loss of £3,569k in funding for the Broadmoor High Secure service in 2009/10 and subsequent years as a consequence of the application of the MEA valuation to assets.
Transitional funding
n/a
Commentary on other revenue
Please explain the significant changes in other revenue
The plan assumes the continuation of R & D funding and MPET funding at current levels. R & D income in 2009/10 is likely to be £492k including £50k that is non recurrent. Consequently £442k is assumed for 2010/11. Changes in R & D funding can be managed through increases or decreases in expenditure.
The Other categoryabove includes catering and accommodation income and rental income for some properties.
Expenditure
Please explain the significant changes in expenditure
Payassumes2.25% national awards plus 1% staff increases as necessary investment tofacilitate CQUIN agreed targets (to be agreed) plus minor developments and incremental drift less CIPs. An estimate of the impact of the Trust strategy to reduce current staff by 5% per annum has been reflected.
Drugs: no significant change assumed for 2010/11.
Clinical Supplies and Services: no significant change assumed for 2010/11.
Depreciation: assumes no change following the five yearly revaluation of assets in 2009/10.
Commentary on overall position
Please provide an explanation of your overall financial position including sections on:
Medium term Financial Strategy and historic debt
Trust has no historic debt.
Trust has reviewed and is in the process of agreeing changes to its medium term financial strategy to reflect the impact of the public sector financial position and the impact of the CQC.
The Trust has planned for 1% surplus based on changes to capital costs. Reduction in capital costs, which are significant, continue to be a key part of the financial strategy. The requirements in the operating framework to demonstrate efficiency in procurement IT, reduction in costs of consultancy will be employed to deliver the strategy. The Trust will benchmark all back office functions and where there are demonstrable and cashable savings, while maintaining or improving quality, consider outsourcing options. The Trust plans that at worst to be revenue neutral as result of carbon reduction strategy and to target achievement of a revenue benefit in future years. In terms of patients care the Trust will work with PCTs and other MH Trusts to consider the potential for efficiency and quality improvements through rationalising services. This is work being planned currently with a view to implementation towards the end of 2010/11 and the impact of any agreed changes will be reflected in future planning. Any significant changes will require consultation among service users, carers and partners and this will take time. This strategy is reflected in this plan by the assumed reduction in current staff by 5% each year. Some of this will be reinvested to deliver the strategic intentions outlined in Section 1.
The Trust strategy is based on partnership approach and recognises that there may be income and service loss where this is part of an overall agreed strategy subject to the overall cost impact being managed across the PCT boundaries (so that Trust is not left with fixed costs). Where Trust gains services and income through this process we would expect similarly not keep windfall gains. No impact of this has been reflected in the plan as the work to identify any major service rationalisation is not complete. The Trust will expect PCTs and other MHTs to agree that fixed costs are not left with the losing Trust to deal with.
Contingency:
0.5% contingency has been included in the plan for both years.
Cash:
The Trust forecasts an overall reduction in the cash balance over the year 2010/11 as capital programmes reach completion and trade creditor payment performance improves.
The impact of IFRS:
The impact of the transition to IFRS has been included in the 2008/09 and 2009/10 accounts. No further adjustments are required in 2010/11 onwards.
Medium term Financial Strategy and historic debt.
Key Assumptions includedwithin the plan
No significant changes in commissioning intentions beyond those already under discussion
The Trust assumes any changes that involve staff will be managed as far as possible through redeployment and avoidance of any compulsory redundancies.
The impact of valuation reductions (not MEA reductions) remain within Trust
The plan incorporates the planning assumptions of NHS London (version 6 11/1/2010):
a)efficiency savings of 3.5% in 2010/11 and 4% in 2011/12;
b)non tariff uplift of zero 2010/11 and a reduction of 0.5% in 2011/12;
c)non recurrent CQUIN of 1.5% of SLA value in both 2010/11 and 2011/12;
d)pay awards 2.25% in 2010/11 and 1% in 2011/12 plus a 1 percentage point increase in employers national insurance; (reflecting December announcement)
e)surplus of 1% of turnover in 2010/11 and 2011/12.
Key risks included within the plan
Explanation of the risk / High/ Medium/ Low risk / Mitigating actions
R & D income varies more than expected / Medium / Expenditure can be increased or reduced as income varies.
CQUIN less than planned / Medium / Total CQUIN funding of £3m has been planned but if this is not achieved expenditure can be reduced as this is treated as non recurrent funding.
Broadmoor OBC not agreed / Medium / Already discussed with Commissioners. Any impact on I & E would be a potential call on Commissioners non recurrent reserves to be discussed.
Bed reductions result in increased pressure to use private sector / High / Cross borough bed management; partnership working to review high DToCs. Continued monitoring of any private sector use.
Further reduction in local authority income / Medium / Renegotiate S31 contract.
MH PbR implemented rapidly Trust identified as high cost provider / Medium/
Low / Improve benchmarking – SLR.
CQUINS
Describe what your commissioners have contracted for in relation to CQUINS
In 2009/10 The Trust agreed CQUIN targets with all commissioners. Funding has been received from high secure and Forensic Commissioners as part of SLA. Local Commissioners have yet to make any payment for QUIN target. Detailed discussions have not yet begun on CQUIN targets for 2010/11.
CQUINS for Local Services
Local Services Quality Performance Incentive Scheme Indicator / Threshold
1. Improvement in the provision of services by WLMHT to clients with a Learning Disability / Improvement in baseline against the Greenlight Toolkit self assessment areas; with demonstrable progress in turning indicators marked Red in 2008-09 to Amber and/or Green in 2009-10.
2. Establish a baseline for physical health checks carried out for all clients on inpatient wards / 100% inpatient clients assessed for physical health needs by Named Nurse within 72 hours of admission to inpatient wards.
All clients to receive an annual physical health check.
3.Delivery of 18 weeks referral to treatment target for all relevant services by 31 March 2010 / 100% delivery of 18 week target for referrals to consultant led services.
4. Improvement in discharge information back to Primary Care / 75% of letters back to primary care referrer following discharge (within 48 hours) by Q2.
95% of letters back to primary care referrer following discharge (within 48 hours) by Q4.
5.CPA to record Accommodation status and Employment of all clients (PSA indicators) / All clients’ accommodation needs and employment status to be captured through CPA process.
CQUINSfor High Secure Service
Quality Performance Incentive Scheme Indicator / Threshold
1. At least 25 hours structured activity per week (including standard 41 on activity) / Target is to increase take up of sessions where appropriate.
Baseline as at 1 April 2009 – to be reported at Q1 review
Peer review December – review of activities offered/taken in case notes.
Report on progress at Q3 review – what is the change from the baseline – include any changes to the range/type of sessions offered and comments why there has been a change.
2. Health check at admission/annual health checks (standard 35/36) / Baseline as at 1 April 2009 – to be reported at Q1 review (from KPIs)
Q3 Review progress – use KPIs and Peer Review
3. Smoking cessation support (standard 37) / Baseline as at 1 April 2009 – to be reported at Q1 review – number of smokers on admission; number offered cessation support within 24 hours.
Q3 - number of smokers on admission; increase in proportion cessation support within 24 hours.
4. Healthy lifestyles (standard 37 and 38) / Baseline – description of plans for change in year; amount of dietetic advice provided; amount of food waste; amount of spend on “red” foods in the shop.
Q3 – evidence of implementation of plans, patient weight changes, any achievement of improvement in BMI levels; reduction in food waste; reduction in the spend on “red” foods in the shop.
5.BMI levels - Standard (39) / Action can be demonstrated to reduce patients BMI range to an acceptable level by December 2009.
Baseline at April 2009 – number of patients within the acceptable BMI limits (i.e. between 18.5 and 30).
Q3 – report of number of patients within the acceptable BMI limits (i.e. between 18.5 and 30).
6. Reduction in suicide (standard 40) / Reports at Q1 on number in 2008/9 and Q3 on number in year to date.
Low and Medium Secure Forensic CQUINs
Quality Performance Incentive Scheme Indicator / Measurement
1. Development of Patient Survey / Development of plan & implementation of survey within year.
2. Relational Security Training / Numbers of staff trained & evaluation.
3. Physical Healthcare Services, to include health screening & smoking cessation / To agree monitoring mechanism, including % service users with physical health check.
4. Physical Health Needs Assessment / Monitoring via Consortium.
5. Mental Health Advocacy / Increase in advocacy provision & reporting to Consortium.
Cost Improvement Programme (expenditure savings only)
Pay CIPs £5.9m a) service redesign leading to forensic medium secure ward closure agreed with commissioners; b) adult acute ward closure; c) smaller local cost improvement programmes
Drug CIPs not significant in 2010/11 but potential of £90k for 2011/12
Clinical Supplies and Services CIPs
Other cost CIPs £1.5mincluding reduced use of private sector
Unidentified CIPs £1.4m currently being identified
For 2011/12 the Trust has identified some potential recurrent savings but this has not been completed in detail and requires further discussion with Commissioners (see medium term financial strategy).
How will the achievement of these savings will be managed in year and what risks are there to achievement?
All CIPs are allocated to specific senior management leads and there is monthly monitoring of the financial position with a bi-monthly finance and performance committee looking at this in more detail. When significant shortfalls in delivery are identified the relevant areas are subject to individual monthly performance monitoring on balanced scorecard basis.
Income generation included in the plan
NHS income over and above signed acute contracts – please give detail of commissioner and amounts
The 2010/11 SLAs are currently being negotiated and the intention is to sign by the due date. Changes from current SLAs are set out in the commentary on clinical revenue
Please give detail of any other material non-NHS income change from last year
The London Borough of Ealing has announced a £304k reduction in the mental health grant paid to the Trust.
Demand management schemes (amount notified by commissioners, have they been included within your plans, how realistic are they, timing of implementation, how are you expecting to manage their impact etc.)
Note: must be scheme specific with clear explanation of implementation, activity reductions and expected benefits
n/a
Capital investment and disposal (including sources of funding)
The Trust is currently awaiting approval for the Outline Business Case for the Broadmoor redevelopment, if received the development will start in 2011/12. Work will begin in 2010/11 on FBC and agreed enabling works. There has been recent discussion with Commissioners regarding required capacity and services at Broadmoor. These changes have not been reflected in this plan as not finalised. The Trust is modelling the impact and when final decisions known will refresh figures.
The Trust has also recently submitted a Strategic Outline case for the St Bernard’s site. The investment and disposal plan reflects the current assumptions for these two developments.
The OBC for St Bernard’s will reflect as necessary any changes to the healthcare delivered on the site as a result of the work described in the strategic overview.
The Trust has also had to manage a significant reduction in the available capital funding thro depreciation funding as a result of the recent District Valuation work. As a result the operational capital plans are being reprioritised.
Key risks and opportunities not included in the financial plans
Key risks not included in the plan with mitigating actions
The Trust is in the process of completion of a new build PICU. The overall male PICU capacity across the Trust is in excess of need. The Trust does not have female PICU capacity. To mitigate income loss and financial risk the Trust will consider options for using some PICU capacity as high intensity beds and discuss with neighbouring Trusts options to purchase female PICU capacity.
The London Borough of Hammersmith & Fulham is making significant cuts to management in mental health social care. This will be discussed as part of S31 negotiation.
Key opportunities not included in the plan with mitigating actions
Trust has not included options to provide shared services.
Could you provide an explanation of the impact of up to a 10% downside funding scenario?
Not currently modelled for non high secure services. Would need further discussion with commissioners to agree what services could be reduced. Would anticipate using retrenchment plans as basis for discussions. In respect of the high Secure OBC the Trust is currently modelling the impact of a range of capacity reductions on variable and semi fixed costs
ALE - plans to improve your score
Finance Reporting:
Areas that the trust will focus on to improve the scores in 2010/11 are:
a) Continue to improve working papers
b) Increase information in the annual report about the Trust’s environmental footprint
c) Ensure the annual report is available in a wide variety of formats.
Financial Management: Financial strategy work to respond to the anticipated public sector financial restraint.
Financial Standing: Already at level 4. Aim to maintain.
Internal Control: Non executive induction in place to ensure risk management is embedded at Board level. (External Audit raised as a result of CQC).
Value for Money: Trust participates in audit commission’s recommended benchmarking for back office functions (CIPFA).Finance Reporting. Using clinical information system to review CMHT efficiency.
WORKFORCE SECTION
Please see appendix 1 for guidance upon completing the table below.